Bill S5800-2011

Relates to implementation of the Affordable Health Care Act

Relates to prescription drug coverage, pre-existing conditions and preventive health care; increases the age of dependent children; provides for choice of health care providers; relates to pediatric care; prohibits lifetime and annual coverage limits; eliminates certain appeal requirements; allows commissioner to devise and implement regulations pertaining thereto.

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Actions

  • Jul 20, 2011: SIGNED CHAP.219
  • Jul 8, 2011: DELIVERED TO GOVERNOR
  • Jun 22, 2011: returned to senate
  • Jun 22, 2011: passed assembly
  • Jun 22, 2011: ordered to third reading rules cal.587
  • Jun 22, 2011: substituted for a8460
  • Jun 20, 2011: referred to insurance
  • Jun 20, 2011: DELIVERED TO ASSEMBLY
  • Jun 20, 2011: PASSED SENATE
  • Jun 20, 2011: ORDERED TO THIRD READING CAL.1376
  • Jun 17, 2011: REFERRED TO RULES

Meetings

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Memo

BILL NUMBER:S5800

TITLE OF BILL:

An act to amend the insurance law and the public health law, in relation to implementation of the federal affordable care act in health insurance policies and contracts

PURPOSE OF BILL:

The purpose of this bill is to amend the Insurance Law and Public Health Law to implement changes required by the federal Affordable Care Act in health insurance policies and contracts.

SUMMARY OF PROVISIONS:

Section 1 of the bill would amend Insurance Law § 3105 to provide that no misrepresentation shall void a contract of hospital, medical, surgical or prescription drug expense insurance unless, in addition to being material, the misrepresentation was intentional.

Sections 2, 24, 31 and 35 of the bill would amend Insurance Law 3216(a)(4), 4235(f)(1) and (2), 4304(d)(1) and (3) and 4305(c)(1) to require a policy or contract of hospital, medical, surgical or prescription drug expense insurance that covers children to provide coverage to a married or unmarried child until attaining age twenty-six, regardless of the child's financial dependence, residency, student status or employment and to make other technical corrections.

Sections 3, 13, and 25 of the bill would amend Insurance Law 3216(i)(9), 3221 (k)(4), and 4303(a)(2) to amend the existing definition of "emergency condition," add definitions of "emergency services," and "to stabilize" and conform the existing requirements for coverage of emergency services with the enhanced protections of 2719A(b) of the Public Health Service Act, 42 U.S.C. § 300gg-19a(b) with respect to grandfathered and non-grandfathered health plans.

Section 4 of the bill would amend Insurance Law § 3216(i)(11) to make technical corrections to the mammography coverage requirements for consistency with Insurance Law §§ 3221 and 4303. Section 4 would also add the mammography coverage requirements of § 2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13 and clarify that the coverage required by the Public Health Service Act shall not be subject to annual deductibles or coinsurance, nor applicable to grandfathered health plans.

Sections 5, 17 and 28 of the bill would amend Insurance Law 3216(i)(15), 3221 (1)(14) and 4303(t) to add the cervical cytology coverage requirements of § 2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13 and to clarify that the coverage required by the Public Health Service Act shall not be subject to annual deductibles or coinsurance, nor applicable to grand fathered health plans.

Sections 6, 15 and 26 of the bill would amend Insurance Law 3216(i)(17), 3221 (1)(8) and 4303(j) to add the preventive care and screening coverage requirements for children and adults of § 2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13 and to clarify that the coverage required by the Public Health Service Act shall not be subject to annual deductibles or coinsurance, nor applicable to grandfathered health plans.

Sections 7, 18 and 29 of the bill would amend Insurance Law 3216(i)(24)(E), 3221 (1)(15)(E), and 4303(aa)(5) to conform the existing definitions of "prehospital emergency medical services" and "emergency condition" with the enhanced protections of § 2719A of the Public Health Service Act, 42 U.S.C. § 300gg-19a for grand fathered and non-grandfathered health plans.

Sections 8,40 and 60 of the bill would amend Insurance Law §§ 3217-c and 4306-b and Public Health Law §§ 4406-b to conform the existing requirements regarding direct access to primary and preventative obstetric and gynecologic services with § 2719A of the Public Health Service Act, 42 USC. § 300gg-19a for grandfathered and nongrandfathered health plans.

Sections 9, 41 and 59 of the bill would add new Insurance Law 3217-e, 4306-d and amend Public Health Law § 4403(7) to require an insurer or HMO that provides for the designation of a primary care provider to permit an insured/enrollee to designate any participating primary care provider who is available to accept the insured/enrollee, and in the case of a child, to permit the insured/enrollee to designate a physician (allopathic or osteopathic) who specializes in pediatrics if such provider participates in the network of the insurer or HMO.

Sections 10 and 42 of the bill would add new Insurance Law §§ 3217-f and 4306-e to prohibit insurers from establishing a lifetime limit on the dollar amount of essential health benefits in an individual, group or blanket policy or contract of hospital, medical, surgical or prescription drug expense insurance; to provide that for policy or contract years beginning January 1,2014, insurers are prohibited from establishing an annual limit on the dollar amount of essential health benefits in an individual, group or blanket policy or contract of hospital, medical, surgical or prescription drug expense insurance, other than a grandfathered individual policy or contract; and to provide that for policy or contract years beginning prior to January 1, 2014, insurers may establish restricted annual limits on the dollar amount of essential health benefits consistent with § 2711 of the Public Health Service Act, 42 U.S.C. § 300gg-11 or any regulations thereunder.

Sections 11, 19, 20 and 21 of the bill would amend Insurance Law 3221(e), 3221(m), 3221(p) and 3221(q) to clarify that the term "dependent" includes a child as described in Insurance Law § 4235(f).

Section 12 of the bill would amend Insurance Law § 3221 (h) with respect to conversion policies to prohibit an insurer from imposing a lifetime limit on benefits that are defined as essential health benefits under § 1302(b) of the Affordable Care Act, 42 U.S.C. 18022(b).

Sections 14 and 30 of the bill would amend Insurance Law 3221(k)(13) and 4303(bb) to add the bone mineral density coverage requirements of §2713 of the Public Health Service Act, 42 U.S.C. 300gg-13 and to clarify that the coverage required by the Public Health Service Act shall not be subject to annual deductibles or coinsurance, nor applicable to grandfathered health plans.

Sections 16 and 27 of the bill would amend Insurance Law §§ 3221 (1)(11) and 4303(p) to add the mammography coverage requirements of 2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13 and to clarify that the coverage required by the Public Health Service Act shall not be subject to annual deductibles or coinsurance, nor applicable to grandfathered health plans.

Sections 22, 34 and 39 of the bill would amend Insurance Law §§ 3221 (r)(1) and (2), 4304(m)(1) and (2) and 4305(1)(1) and (2) to make technical corrections to provisions regarding coverage for children until age 29.

Sections 23 and 43 of the bill would add new Insurance Law §§ 3232(f), (g), (h), (i) and (j) and 4318(f), (g), (h), (i) and (j) to prohibit insurers in an individual, group or blanket policy or contract of hospital, medical, surgical or prescription drug expense insurance, other than in an individual policy or contract that is a grandfathered health plan, from imposing a pre-existing condition exclusion on children under the age of 19, for consistency with 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3. Sections 23 and 43 would also provide that beginning January 1, 2014, pursuant to the requirements of §2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3 insurers are prohibited from imposing a pre-existing condition exclusion in any individual, group or blanket policy of hospital, medical, surgical or prescription drug expense insurance other than in an individual policy or contract that is a grandfathered health plan.

Sections 32 and 33 of the bill would amend Insurance Law §§ 4304(e) and 4304(k)(5) to clarify that the term "dependent" includes a child as described in Insurance Law § 4304(d).

Sections 36, 37 and 38 of the bill would amend Insurance Law 4305(d), 4305(e) and 4305(k) to clarify that the term "dependent" includes a child as described in Insurance Law § 4305(c).

Section 44 of the bill would amend Insurance Law § 4321 (c) to provide that with respect to non-grand fathered standardized HMO direct payment contracts, no copayment shall apply to preventive services or bone mineral density coverage required pursuant to § 2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13.

Section 45 of the bill would add a new Insurance Law § 4322(b)(4)(F) to require that non-grand fathered standardized HMO and POS direct payment contracts provide coverage for preventive health services required by § 2713 of the Public Health Service Act, 42 U.S.C. 300gg-13.

Section 46 of the bill would amend Insurance Law § 4322(b)(26) to require that non-grandfathered standardized HMO and POS direct

payment contracts provide bone mineral density coverage required by 2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13.

Section 47 of the bill would amend Insurance Law § 4322(c) and (d) to provide that no copayment shall apply to preventive services or bone mineral density coverage required pursuant to § 2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13. Section 47 would further provide that an out-of-plan lifetime benefit maximum shall not apply to any benefit defined as an essential health benefit in § 1302(b) of the Affordable Care Act, 42 U.S.C. § 18022(b).

Section 48 of the bill would add a new Insurance Law § 4326(d)(15) to require that non-grandfathered Healthy New York contracts provide coverage for preventive health services required by § 2713 of the Public Health Service Act, 42 U.S.C. § 300gg-13.

Section 49 of the bill would amend Insurance Law §4326(e)(6) and (7) to require an individual Healthy New York contract that is a grandfathered health plan to maintain the $3,000 calendar year limit on prescription drug coverage; to provide that the maximum dollar amount on coverage for prescription drugs in an individual contract that is not a grand fathered health plan or in any group contract shall be consistent with §2711 of the Public Health Service Act, 42 U.S.C. § 300gg-11 or any regulations thereunder; and to provide that a copayment shall not apply to preventive health services provided in accordance with Insurance Law § 4322(d)(15).

Section 50 of the bill would amend Insurance Law § 4326(k) to prohibit a Healthy New York contract, other than an individual contract that is a grand fathered health plan, from imposing a pre-existing condition exclusion on children under the age of 19 for conformance with § 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3. Section 51 would also prohibit a Healthy New York contract, other than a grand fathered individual contract, from imposing a pre-existing condition exclusion beginning January 1, 2014, pursuant to the requirements of § 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3.

Sections 51 and 61 of the bill would amend Insurance Law § 4900(c) and Public Health Law § 4900(3) to amend the definition of "emergency condition" for conformance with § 2719A(b) of the Public Health Service Act, 42 U.S.C. § 300gg-19a(b).

Sections 52 and 62 of the bill would amend Insurance Law § 4900(g-7) and Public Health Law § 4900(7-g) to remove the requirement that an insured or enrollee have a life-threatening or disabling condition or disease to be eligible for an external appeal of a rare disease.

Sections 53 and 63 of the bill would amend Insurance Law 4910(b)(1)(A) and (B) and Public Health Law § 4910(2)(a)(i) and (ii) to permit an insured or enrollee to pursue an external appeal when a health care service does not meet the health care plan's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness of a covered benefit including when the insured or enrollee is deemed to have exhausted or is not required to complete an internal appeal pursuant to § 2719 of the Public Health Service Act, 42 U.S.C. § 300gg-19.

Sections 54 and 64 of the bill would amend Insurance Law 4910(b)(2)(A), (B) and (C) and Public Health Law § 4910(2)(b)(i), (ii) and (iii) to permit an insured or enrollee to pursue an external appeal of an experimental or investigational treatment denial when the insured or enrollee is deemed to have exhausted or is not required to complete an internal appeal pursuant to § 2719 of the Public Health Service Act, 42 U.S.C. § 300gg-19 and to remove the requirement that an insured or enrollee have a life threatening or disabling condition or disease to be eligible for an external appeal of an experimental or investigational treatment denial.

Sections 55 and 65 of the bill would amend Insurance Law § 4910(c) and Public Health Law § 4910(3) to reduce the $50 fee that a health care plan may currently charge an insured or enrollee for an external appeal to $25 and to provide that an insured or enrollee shall not pay more than $75 within a single plan year.

Sections 56 and 66 of the bill would add new Insurance Law 4912(b)(6) and Public Health Law § 4912(2)(f) to require an organization to be accredited by a nationally recognized private accrediting organization in order to be a certified as an external appeal agent.

Sections 57 and 67 of the bill would amend Insurance Law § 4914(b)(1) and (3) and Public Health Law § 49l4(2)(a) and (c) to provide that an insured or enrollee shall have four months to file an external appeal; to permit an insured or enrollee to obtain an expedited external appeal for reasons permitted by § 2719 of the Public Health Service Act, 42 U.S.C § 300gg-19; and to require that an expedited external appeal be completed in no more than 72 hours.

Sections 58 and 68 of the bill would amend Insurance Law 4914(b)(4)(B)(ii)(a) and Public Health Law § 4914(2)(d)(B)(ii)(1) to remove the requirement that an insured or enrollee have a life-threatening or disabling condition or disease to be eligible for an external appeal of an experimental or investigational treatment denial.

Section 69 of the bill would provide that if any provision of the act or the application thereof shall be held to be invalid, such invalidity shall not affect other provisions of the act which can be given effect without the invalid provision, and, to that end, the provisions of the act are severable.

Section 70 of the bill sets forth the effective date.

EXISTING LAW:

Insurance Law § 3105 addresses representations by the insured. Insurance Law § 3216 sets forth the requirements for individual accident and health insurance policies issued by commercial insurers. Insurance Law §§ 3217-c and 4306-b and Public Health Law § 4406-b set forth requirements for an insured's direct access to primary and preventive obstetric and gynecologic care. Insurance Law §3221 sets forth requirements for group and blanket accident and health insurance policies issued by commercial insurers. Insurance Law 3232 and 4318 set forth requirements for pre-existing condition

exclusions in health insurance policies. Insurance Law § 4235 sets forth requirements for group accident and health insurance policies issued by commercial insurers, including permissible groups. Insurance Law § 4303 sets forth benefit requirements for contracts issued by Article 43 corporations. Insurance Law § 4304 sets forth requirements for individual contracts issued by Article 43 corporations. Insurance Law § 4305 sets forth requirements for group contracts issued by Article 43 corporations. Insurance Law §§ 4321 and 4322 set forth the requirements for standardized direct payment contracts issued by health maintenance organizations. Insurance Law § 4326 sets forth the requirements for individual and small group contracts issued under the Healthy New York program. Article 49 of the Insurance Law and the Public Health Law establishes a right to utilization review and external appeal for consumers and, in certain cases, health care providers. Public Health Law § 4403 sets forth standards for issuance of a certificate of authority for a health maintenance organization.

PRIOR LEGISLATIVE HISTORY:

This is a new bill.

STATEMENT IN SUPPORT:

The Patient Protection and Affordable Care Act, Pub. L. 111-148, was enacted on March 23, 2010. The Health Care and Education Reconciliation Act, Pub. L. 111-152, was enacted on March 30, 2010. These Acts, collectively referred to as the "Affordable Care Act", establish consumer protections and mandated benefit requirements ("six month reforms") that apply to health insurance policies issued or renewed on or after September 23, 2010. The Departments of Treasury, Labor, and Health and Human Services also issued several interim regulations to clarify and implement certain provisions of the Affordable Care Act.

The Affordable Care Act and regulations promulgated thereunder include the following protections: requirements for coverage of preventive services for children and adults with no cost-sharing; coverage of children to age 26 regardless of financial dependency, residency, student status or employment; prohibitions on pre-existing condition exclusions for children up to age 19; direct access to obstetric and gynecologic services; choice of primary care physician; coverage of out-of-network emergency services without pre-authorization; internal and external appeals; prohibitions on the dollar amount of lifetime and annual limits with respect to essential health benefits; and permitting rescissions only for fraud or intentional misrepresentation of material fact.

The Affordable Care Act does not preempt state laws that meet or exceed protections offered in the Affordable Care Act. However, state laws that do not meet or exceed the Affordable Care Act protections must be amended for compliance with the Affordable Care Act. New York State Insurance Law and Public Health Law currently include provisions relating to the areas addressed by the "six month changes". This bill would ensure that existing protections in New York State Insurance Law and Public Health Law that meet or exceed the Affordable Care Act protections are maintained, while remaining

provisions are brought into compliance. To the extent that there is overlap between the existing state requirements for coverage of preventive health services and the new Affordable Care Act requirements, coverage must be provided for those overlapping preventive health services with no cost sharing.

Certain Affordable Care Act requirements do not apply to policies that were in effect on March 23, 2010, the date the Affordable Care Act was enacted ("grandfathered health plans"). This bill would maintain the exception for "grand fathered health plans" other than with respect to the requirements for direct access to obstetric and gynecologic services, choice of primary care physician, coverage of emergency services and external appeals. The exception for "grand fathered health plans" was not maintained in the bill with respect to requirements for direct access to obstetric and gynecologic services and choice of primary care physician because existing New York requirements are very similar to the Affordable Care Act requirements and extending the Affordable Care Act requirements would provide consistency among coverages, without impacting cost. In addition, the exception for "grand fathered health plans" was not maintained with respect to requirements for coverage of emergency services and external appeals because uniformity is needed in these areas for consistent claims handling and costs should not be impacted.

The changes contained in this bill are necessary in order for New York State to implement and enforce the federal standards enacted in the Affordable Care Act and the regulations promulgated thereunder.

BUDGET IMPLICATIONS:

There are no budget implications from this bill.

EFFECTIVE DATE:

This bill would take effect immediately. However, for policies renewed on or after that date but before September 23, 2011, the act would take effect upon the renewal date. Further, sections eight, nine, ten, fourteen, fifteen, sixteen, seventeen, eighteen, twenty-three, twenty-six, twenty-seven, twenty-eight, twenty-nine, thirty, forty, forty-one, forty-two and forty-three of the act would, with respect to blanket policies of hospital, medical, surgical or prescription drug expense insurance covering students pursuant to Insurance Law 4237(a)(3)(C), take effect on January 1, 2012 and apply to policies issued or renewed on or after that date. Further, sections fifty-two, fifty-three, fifty-four, fifty-five, fifty-six, fifty-seven, fifty-eight, sixty-two, sixty-three, sixty-four, sixty-five, sixty-six, sixty-seven and sixty-eight of the act would take effect on the later of July 1, 2011 or the date the external appeal requirements of § 2719 of the Public Health Service Act, 42 U.S.C. 300gg-19 are determined to be effective by the Secretary of Health and Human Services and apply to a final adverse determination issued on and after that date.


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STATE OF NEW YORK ________________________________________________________________________ 5800 2011-2012 Regular Sessions IN SENATE June 17, 2011 ___________
Introduced by Sen. SEWARD -- (at request of the New York State Insurance Department) -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the insurance law and the public health law, in relation to implementation of the federal affordable care act in health insur- ance policies and contracts THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Subsection (b) of section 3105 of the insurance law is amended to read as follows: (b)(1) No misrepresentation shall avoid any contract of insurance or defeat recovery thereunder unless such misrepresentation was material. No misrepresentation shall be deemed material unless knowledge by the insurer of the facts misrepresented would have led to a refusal by the insurer to make such contract. (2) WITH RESPECT TO A POLICY OF HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE SUBJECT TO ARTICLES THIRTY-TWO OR FORTY-THREE OF THIS CHAPTER, NO MISREPRESENTATION SHALL AVOID ANY CONTRACT OF INSURANCE OR DEFEAT RECOVERY THEREUNDER UNLESS THE MISREPRE- SENTATION WAS ALSO INTENTIONAL. S 2. Subsection (a) of section 3216 of the insurance law, paragraph 4 as amended by section 65-d of part A of chapter 58 of the laws of 2007, and subparagraph (C) of paragraph 4 as added by chapter 240 of the laws of 2009, is amended to read as follows: (a) In this section the term: (1) "Policy of accident and health insurance" includes any individual policy or contract covering the kind or kinds of insurance described in paragraph three of subsection (a) of section one thousand one hundred thirteen of this chapter. (2) "Indemnity" means benefits promised.
(3) "Family" may include [husband, wife] THE POLICYHOLDER'S SPOUSE, or dependent children, or any other person dependent upon the policyholder. (4) "Dependent children" (A) shall include any children under a speci- fied age which shall not exceed age nineteen except: (i) Any unmarried dependent child, regardless of age, who is incapable of self-sustaining employment by reason of mental illness, developmental disability, or mental retardation as defined in the mental hygiene law, or physical handicap and who became so incapable prior to the age at which dependent coverage would otherwise terminate, shall be included in coverage subject to any pre-existing conditions limitation applicable to other dependents[.]; OR (ii) Any unmarried student at an accredited institution of learning may be considered a dependent child until attaining age twenty-three[.] FOR A POLICY OTHER THAN HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE; OR (III) ANY MARRIED OR UNMARRIED CHILD SHALL BE CONSIDERED A DEPENDENT CHILD UNTIL ATTAINING AGE TWENTY-SIX WITHOUT REGARD TO FINANCIAL DEPEND- ENCE, RESIDENCY WITH THE POLICYHOLDER, STUDENT STATUS, OR EMPLOYMENT, FOR A POLICY OF HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE. (B) may include, at the option of the insurer, any unmarried child until attaining age twenty-five FOR A POLICY OTHER THAN HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE. (C) In addition to the requirements of subparagraphs (A) and (B) of this paragraph, every insurer issuing a policy OF HOSPITAL, MEDICAL, OR SURGICAL EXPENSE INSURANCE pursuant to this section that provides cover- age for dependent children must make available and, if requested by the policyholder, extend coverage under the policy to an unmarried child through age twenty-nine, without regard to financial dependence who is not insured by or eligible for coverage under an employer [sponsored] health benefit plan [covering them] as an employee or member, whether insured or self-insured, and who lives, works or resides in New York state or the service area of the insurer. Such coverage shall be made available at the inception of all new policies [and at the first anni- versary date of a policy following the effective date of this subpara- graph]. Written notice of the availability of such coverage shall be delivered to the policyholder thirty days prior to the inception of such [group] policy [and thirty days prior to the first anniversary date following the effective date of this subparagraph]. S 3. Paragraph 9 of subsection (i) of section 3216 of the insurance law, as added by chapter 705 of the laws of 1996, is amended to read as follows: (9)(A) Every policy [which] THAT provides coverage for inpatient hospital care shall also include coverage for services to treat an emer- gency condition in hospital facilities[. An]: (I) WITHOUT THE NEED FOR ANY PRIOR AUTHORIZATION DETERMINATION; (II) REGARDLESS OF WHETHER THE HEALTH CARE PROVIDER FURNISHING SUCH SERVICES IS A PARTICIPATING PROVIDER WITH RESPECT TO SUCH SERVICES; (III) IF THE EMERGENCY SERVICES ARE PROVIDED BY A NON-PARTICIPATING PROVIDER, WITHOUT IMPOSING ANY ADMINISTRATIVE REQUIREMENT OR LIMITATION ON COVERAGE THAT IS MORE RESTRICTIVE THAN THE REQUIREMENTS OR LIMITA- TIONS THAT APPLY TO EMERGENCY SERVICES RECEIVED FROM PARTICIPATING PROVIDERS; AND (IV) IF THE EMERGENCY SERVICES ARE PROVIDED BY A NON-PARTICIPATING PROVIDER, THE COST-SHARING REQUIREMENT (EXPRESSED AS A COPAYMENT OR
COINSURANCE) SHALL BE THE SAME REQUIREMENT THAT WOULD APPLY IF SUCH SERVICES WERE PROVIDED BY A PARTICIPATING PROVIDER. (B) ANY REQUIREMENTS OF SECTION 2719A(B) OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG19A(B) AND REGULATIONS THEREUNDER THAT EXCEED THE REQUIREMENTS OF THIS PARAGRAPH WITH RESPECT TO COVERAGE OF EMERGENCY SERVICES SHALL BE APPLICABLE TO EVERY POLICY SUBJECT TO THIS PARAGRAPH. (C) FOR PURPOSES OF THIS PARAGRAPH, AN "emergency condition" means a medical or behavioral condition[, the onset of which is sudden,] that manifests itself by ACUTE symptoms of sufficient severity, including severe pain, SUCH that a prudent layperson, possessing an average know- ledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in [(A)] (I) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy[, or (B)]; (II) serious impairment to such person's bodily functions; [(C)] (III) serious dysfunction of any bodily organ or part of such person; [or (D)] (IV) serious disfigurement of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. (D) FOR PURPOSES OF THIS PARAGRAPH, "EMERGENCY SERVICES" MEANS, WITH RESPECT TO AN EMERGENCY CONDITION: (I) A MEDICAL SCREENING EXAMINATION AS REQUIRED UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, WHICH IS WITHIN THE CAPABILITY OF THE EMERGENCY DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY AVAILABLE TO THE EMER- GENCY DEPARTMENT TO EVALUATE SUCH EMERGENCY MEDICAL CONDITION; AND (II) WITHIN THE CAPABILITIES OF THE STAFF AND FACILITIES AVAILABLE AT THE HOSPITAL, SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT AS ARE REQUIRED UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, TO STABILIZE THE PATIENT. (E) FOR PURPOSES OF THIS PARAGRAPH, "TO STABILIZE" MEANS, WITH RESPECT TO AN EMERGENCY CONDITION, TO PROVIDE SUCH MEDICAL TREATMENT OF THE CONDITION AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE MEDICAL PROB- ABILITY, THAT NO MATERIAL DETERIORATION OF THE CONDITION IS LIKELY TO RESULT FROM OR OCCUR DURING THE TRANSFER OF THE INSURED FROM A FACILITY OR TO DELIVER A NEWBORN CHILD (INCLUDING THE PLACENTA). S 4. Paragraph 11 of subsection (i) of section 3216 of the insurance law, as added by chapter 417 of the laws of 1989, is amended to read as follows: (11) (A) Every policy [which] THAT provides coverage for hospital, surgical or medical care shall provide the following coverage for mammography screening for occult breast cancer: (i) upon the recommendation of a physician, a mammogram at any age for covered persons having a prior history of breast cancer or [whose mother or sister has] WHO HAVE A FIRST DEGREE RELATIVE WITH a prior history of breast cancer; (ii) a single baseline mammogram for covered persons aged thirty-five through thirty-nine, inclusive; AND (iii) [a mammogram every two years, or more frequently upon the recom- mendation of a physician, for covered persons aged forty through forty- nine, inclusive; and (iv)] an annual mammogram for covered persons aged [fifty] FORTY and older. (B) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (C) OF THIS PARAGRAPH may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy.
(C) For purposes OF SUBPARAGRAPHS (A) AND (B) of this paragraph, mammography screening means an X-ray examination of the breast using dedicated equipment, including X-ray tube, filter, compression device, screens, films and cassettes, with an average glandular radiation dose less than 0.5 rem per view per breast. (D) IN ADDITION TO SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH, EVERY POLICY THAT PROVIDES COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (E) OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING MAMMOGRAPHY SCREENING SERVICES, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (I) EVIDENCE-BASED ITEMS OR SERVICES FOR MAMMOGRAPHY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (II) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS FOR MAMMOGRAPHY NOT DESCRIBED IN ITEM (I) OF THIS SUBPARA- GRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN- TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 5. Paragraph 15 of subsection (i) of section 3216 of the insurance law, as amended by chapter 43 of the laws of 1993, is amended to read as follows: (15) (A) Every policy [which] THAT provides hospital, surgical or medical care coverage or provides reimbursement for laboratory tests or reimbursement for diagnostic X-ray services shall provide coverage for an annual cervical cytology screening for cervical cancer and its precursor states for women aged eighteen and older. (B) For purposes OF SUBPARAGRAPHS (A) AND (C) of this paragraph, cervical cytology screening shall include an annual pelvic examination, collection and preparation of a Pap smear, and laboratory and diagnostic services provided in connection with examining and evaluating the Pap smear. (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS PARAGRAPH may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. (D) IN ADDITION TO SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH, EVERY POLICY THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (E) OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING CERVICAL CYTOLOGY SCREENING SERVICES, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (I) EVIDENCE-BASED ITEMS OR SERVICES FOR CERVICAL CYTOLOGY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (II) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS FOR CERVICAL CYTOLOGY NOT DESCRIBED IN ITEM (I) OF THIS SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN-
TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 6. Paragraph 17 of subsection (i) of section 3216 of the insurance law, as added by chapter 728 of the laws of 1993, is amended to read as follows: (17) (A) Every policy [which] THAT provides medical, major-medical or similar comprehensive-type coverage shall provide coverage for the provision of preventive and primary care services. (B) For the purposes OF SUBPARAGRAPHS (A), (C) AND (D) of this para- graph, preventive and primary care services means the following services rendered to a [dependent] COVERED child of an insured from the date of birth through the attainment of nineteen years; (i) an initial hospital check-up and well-child visits scheduled in accordance with the prevailing clinical standards of a national associ- ation of pediatric physicians designated by the commissioner of health (except for any standard that would limit the specialty or forum of licensure of the practitioner providing the service other than the limits under state law). Coverage for such services rendered shall be provided only to the extent that such services are provided by or under the supervision of a physician, or other professional licensed under article one hundred thirty-nine of the education law whose scope of practice pursuant to such law includes the authority to provide the specified services. Coverage shall be provided for such services rendered in a hospital, as defined in section twenty-eight hundred one of the public health law, or in an office of a physician or other professional licensed under article one hundred thirty-nine of the education law whose scope of practice pursuant to such law includes the authority to provide the specified services; (ii) at each visit, services in accordance with the prevailing clin- ical standards of such designated association, including a medical history, a complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests which tests are ordered at the time of the visit and performed in the practitioner's office, as authorized by law, or in a clinical laborato- ry; and (iii) necessary immunizations, as determined by the superintendent in consultation with the commissioner of health, consisting of at least adequate dosages of vaccine against diphtheria, pertussis, tetanus, polio, measles, rubella, mumps, haemophilus influenzae type b and hepa- titis b, which meet the standards approved by the United States public health service for such biological products. (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS PARAGRAPH shall not be subject to annual deductibles [and/or] OR coinsu- rance. (D) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS PARAGRAPH shall not restrict or eliminate existing coverage provided by the policy. (E) IN ADDITION TO SUBPARAGRAPH (A), (B), (C) OR (D) OF THIS PARA- GRAPH, EVERY POLICY THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (F) OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING PREVENTIVE CARE AND SCREENINGS FOR INSUREDS, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (I) EVIDENCE-BASED ITEMS OR SERVICES FOR PREVENTIVE CARE AND SCREEN- INGS THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMEN- DATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE;
(II) IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI- SORY COMMITTEE ON IMMUNIZATION PRACTICES OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED; (III) WITH RESPECT TO CHILDREN, INCLUDING INFANTS AND ADOLESCENTS, EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS PROVIDED FOR IN COMPRE- HENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMIN- ISTRATION; AND (IV) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS NOT DESCRIBED IN ITEM (I) OF THIS SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (F) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN- TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 7. Subparagraph (E) of paragraph 24 of subsection (i) of section 3216 of the insurance law, as added by chapter 506 of the laws of 2001, is amended to read as follows: (E) As used in this paragraph: (i) "Prehospital emergency medical services" means the prompt evalu- ation and treatment of an emergency medical condition, and/or non-air- borne transportation of the patient to a hospital, provided however, where the patient utilizes non-air-borne emergency transportation pursu- ant to this paragraph, reimbursement [will] SHALL be based on whether a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of such transportation to result in [(1)] (I) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; [(2)] (II) serious impairment to such person's bodily functions; [(3)] (III) serious dysfunction of any bodily organ or part of such person; [or (4)] (IV) serious disfigurement of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II), OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. (ii) "Emergency condition" means a medical or behavioral condition[, the onset of which is sudden,] that manifests itself by ACUTE symptoms of sufficient severity, including severe pain, SUCH that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in [(1)] (I) placing the health of the person afflicted with such condi- tion in serious jeopardy, or in the case of a behavioral condition plac- ing the health of such person or others in serious jeopardy; [(2)] (II) serious impairment to such person's bodily functions; [(3)] (III) seri- ous dysfunction of any bodily organ or part of such person; [or (4)] (IV) serious disfigurement of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II), OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. S 8. Section 3217-c of the insurance law, as added by chapter 554 of the laws of 2002, is amended to read as follows: S 3217-c. Primary and preventive obstetric and gynecologic care. (a) No insurer subject to this article shall by contract, written policy or procedure limit a female insured's direct access to primary and preven- tive obstetric and gynecologic services, INCLUDING ANNUAL EXAMINATIONS, CARE RESULTING FROM SUCH ANNUAL EXAMINATIONS, AND TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, from a qualified provider of such services of
her choice from within the plan [to less than two examinations annually for such services] or [to] FOR any care related to a pregnancy[. In addition, no insurer subject to this article shall by contract, written policy or procedure limit direct access to primary and preventive obstetric and gynecologic services required as a result of such annual examinations or as a result of an acute gynecologic condition], provided that: (1) such qualified provider discusses such services and treatment plan with the insured's primary care practitioner in accordance with the requirements of the insurer; AND (2) SUCH QUALIFIED PROVIDER AGREES TO ADHERE TO THE INSURER'S POLICIES AND PROCEDURES, INCLUDING ANY APPLICA- BLE PROCEDURES REGARDING REFERRALS AND OBTAINING PRIOR AUTHORIZATION FOR SERVICES OTHER THAN OBSTETRIC AND GYNECOLOGIC SERVICES RENDERED BY SUCH QUALIFIED PROVIDER, AND AGREES TO PROVIDE SERVICES PURSUANT TO A TREAT- MENT PLAN (IF ANY) APPROVED BY THE INSURER. (b) AN INSURER SHALL TREAT THE PROVISION OF OBSTETRIC AND GYNECOLOGIC CARE, AND THE ORDERING OF RELATED OBSTETRIC AND GYNECOLOGIC ITEMS AND SERVICES, PURSUANT TO THE DIRECT ACCESS DESCRIBED IN SUBSECTION (A) OF THIS SECTION BY A PARTICIPATING QUALIFIED PROVIDER OF SUCH SERVICES, AS THE AUTHORIZATION OF THE PRIMARY CARE PROVIDER. (C) It shall be the duty of the administrative officer or other person in charge of each insurer subject to THE PROVISIONS OF this article to advise each female insured, in writing, of the provisions of this section. S 9. The insurance law is amended by adding a new section 3217-e to read as follows: S 3217-E. CHOICE OF HEALTH CARE PROVIDER. AN INSURER THAT IS SUBJECT TO THIS ARTICLE AND REQUIRES OR PROVIDES FOR DESIGNATION BY AN INSURED OF A PARTICIPATING PRIMARY CARE PROVIDER SHALL PERMIT THE INSURED TO DESIGNATE ANY PARTICIPATING PRIMARY CARE PROVIDER WHO IS AVAILABLE TO ACCEPT SUCH INDIVIDUAL, AND IN THE CASE OF A CHILD, SHALL PERMIT THE INSURED TO DESIGNATE A PHYSICIAN (ALLOPATHIC OR OSTEOPATHIC) WHO SPECIALIZES IN PEDIATRICS AS THE CHILD'S PRIMARY CARE PROVIDER IF SUCH PROVIDER PARTICIPATES IN THE NETWORK OF THE INSURER. S 10. The insurance law is amended by adding a new section 3217-f to read as follows: S 3217-F. PROHIBITION ON LIFETIME AND ANNUAL LIMITS. (A) AN INSURER SHALL NOT ESTABLISH A LIFETIME LIMIT ON THE DOLLAR AMOUNT OF ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP OR BLANKET POLICY OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE. (B) AN INSURER SHALL NOT ESTABLISH AN ANNUAL LIMIT ON THE DOLLAR AMOUNT OF ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP OR BLANKET POLICY OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE FOR POLICY YEARS BEGINNING ON AND AFTER JANUARY ONE, TWO THOU- SAND FOURTEEN. (C) FOR POLICY YEARS BEGINNING PRIOR TO JANUARY ONE, TWO THOUSAND FOURTEEN, AN INSURER MAY ESTABLISH RESTRICTED ANNUAL LIMITS ON THE DOLLAR AMOUNT OF ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP, OR BLANKET POLICY OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE CONSISTENT WITH SECTION 2711 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-11 OR ANY REGULATIONS THEREUNDER. (D) THE REQUIREMENTS OF SUBSECTIONS (B) AND (C) OF THIS SECTION SHALL NOT BE APPLICABLE TO AN INDIVIDUAL POLICY THAT IS A GRANDFATHERED HEALTH PLAN. FOR PURPOSES OF THIS SECTION, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN-
TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). (E) FOR PURPOSES OF THIS SECTION, "ESSENTIAL HEALTH BENEFITS" SHALL HAVE THE MEANING ASCRIBED BY SECTION 1302(B) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B). S 11. Subsection (e) of section 3221 of the insurance law is amended by adding a new paragraph 12 to read as follows: (12) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (F) OF SECTION FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER. S 12. Subsection (h) of section 3221 of the insurance law is amended by adding a new paragraph 5 to read as follows: (5) FOR THE PURPOSE OF DETERMINING THE BENEFITS PAYABLE FOR A COVERED PERSON, AN INSURER SHALL NOT IMPOSE A LIFETIME LIMIT ON THE DOLLAR AMOUNT OF BENEFITS THAT ARE DEFINED AS ESSENTIAL HEALTH BENEFITS PURSU- ANT TO SECTION 1302(B) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B). S 13. Paragraph 4 of subsection (k) of section 3221 of the insurance law, as added by chapter 705 of the laws of 1996, is amended to read as follows: (4) (A) Every group policy delivered or issued for delivery in this state [which] THAT provides coverage for inpatient hospital care shall include coverage for services to treat an emergency condition provided in hospital facilities, except that this provision shall not apply to a policy which [cover] COVERS persons employed in more than one state or the benefit structure of which was the subject of collective bargaining affecting persons who are employed in more than one state UNLESS THE POLICY OTHERWISE PROVIDES COVERAGE FOR SERVICES TO TREAT AN EMERGENCY CONDITION PROVIDED IN HOSPITAL FACILITIES: (I) WITHOUT THE NEED FOR ANY PRIOR AUTHORIZATION DETERMINATION; (II) REGARDLESS OF WHETHER THE HEALTH CARE PROVIDER FURNISHING SUCH SERVICES IS A PARTICIPATING PROVIDER WITH RESPECT TO SUCH SERVICES; (III) IF THE EMERGENCY SERVICES ARE PROVIDED BY A NON-PARTICIPATING PROVIDER, WITHOUT IMPOSING ANY ADMINISTRATIVE REQUIREMENT OR LIMITATION ON COVERAGE THAT IS MORE RESTRICTIVE THAN THE REQUIREMENTS OR LIMITA- TIONS THAT APPLY TO EMERGENCY SERVICES RECEIVED FROM PARTICIPATING PROVIDERS; AND (IV) IF THE EMERGENCY SERVICES ARE PROVIDED BY A NON-PARTICIPATING PROVIDER, THE COST-SHARING REQUIREMENT (EXPRESSED AS A COPAYMENT OR COINSURANCE) SHALL BE THE SAME REQUIREMENT THAT WOULD APPLY IF SUCH SERVICES WERE PROVIDED BY A PARTICIPATING PROVIDER. (B) ANY REQUIREMENTS OF SECTION 2719A(B) OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG19A(B) AND REGULATIONS THEREUNDER THAT EXCEED THE REQUIREMENTS OF THIS PARAGRAPH WITH RESPECT TO COVERAGE OF EMERGENCY SERVICES SHALL BE APPLICABLE TO EVERY POLICY SUBJECT TO THIS PARAGRAPH. (C) In this paragraph, an "emergency condition" means a medical or behavioral condition[, the onset of which is sudden,] that manifests itself by ACUTE symptoms of sufficient severity, including severe pain, SUCH that a prudent layperson, possessing an average knowledge of medi- cine and health, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy[, or]; (ii) serious impairment to such person's bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; [or] (iv) serious disfigurement of such person; OR (V) A CONDI-
TION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. (D) IN THIS PARAGRAPH, "EMERGENCY SERVICES" MEANS, WITH RESPECT TO AN EMERGENCY CONDITION: (I) A MEDICAL SCREENING EXAMINATION AS REQUIRED UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, WHICH IS WITHIN THE CAPABILITY OF THE EMERGENCY DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY AVAILABLE TO THE EMERGENCY DEPARTMENT TO EVALUATE SUCH EMERGENCY MEDICAL CONDITION: AND (II) WITHIN THE CAPABILITIES OF THE STAFF AND FACILITIES AVAILABLE AT THE HOSPITAL, SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT AS ARE REQUIRED UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, TO STABI- LIZE THE PATIENT. (E) IN THIS PARAGRAPH, "TO STABILIZE" MEANS, WITH RESPECT TO AN EMER- GENCY CONDITION, TO PROVIDE SUCH MEDICAL TREATMENT OF THE CONDITION AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION OF THE CONDITION IS LIKELY TO RESULT FROM OR OCCUR DURING THE TRANSFER OF THE INSURED FROM A FACILITY OR TO DELIVER A NEWBORN CHILD (INCLUDING THE PLACENTA). S 14. Paragraph 13 of subsection (k) of section 3221 of the insurance law, as added by chapter 554 of the laws of 2002, is amended to read as follows: (13) Every group or blanket policy delivered or issued for delivery in this state [which] THAT provides major medical or similar comprehen- sive-type coverage shall provide such coverage for bone mineral density measurements or tests, and if such contract otherwise includes coverage for prescription drugs, drugs and devices approved by the federal food and drug administration or generic equivalents as approved substitutes. In determining appropriate coverage provided by SUBPARAGRAPHS (A), (B) AND (C) OF this paragraph, the insurer or health maintenance organiza- tion shall adopt standards [which] THAT include the criteria of the federal [medicare] MEDICARE program and the criteria of the national institutes of health for the detection of osteoporosis, provided that such coverage shall be further determined as follows: (A) for purposes OF SUBPARAGRAPHS (B) AND (C) of this paragraph, bone mineral density measurements or tests, drugs and devices shall include those covered under the federal Medicare program as well as those in accordance with the criteria of the national institutes of health, including, as consistent with such criteria, dual-energy x-ray absorp- tiometry. (B) for purposes OF SUBPARAGRAPHS (A) AND (C) of this paragraph, bone mineral density measurements or tests, drugs and devices shall be covered for individuals meeting the criteria under the federal Medicare program or the criteria of the national institutes of health; provided that, to the extent consistent with such criteria, individuals qualify- ing for coverage shall at a minimum, include individuals: (i) previously diagnosed as having osteoporosis or having a family history of osteoporosis; or (ii) with symptoms or conditions indicative of the presence, or the significant risk, of osteoporosis; or (iii) on a prescribed drug regimen posing a significant risk of osteo- porosis; or (iv) with lifestyle factors to such a degree as posing a significant risk of osteoporosis; or (v) with such age, gender and/or other physiological characteristics which pose a significant risk for osteoporosis.
(C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS PARAGRAPH may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. (D) IN ADDITION TO SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH, EVERY GROUP OR BLANKET POLICY THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (E) OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING ITEMS OR SERVICES FOR BONE MINERAL DENSITY AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (I) EVIDENCE-BASED ITEMS OR SERVICES FOR BONE MINERAL DENSITY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (II) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS FOR BONE MINERAL DENSITY NOT DESCRIBED IN ITEM (I) OF THIS SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN- TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 15. Paragraph 8 of subsection (l) of section 3221 of the insurance law, as amended by chapter 728 of the laws of 1993, is amended to read as follows: (8) (A) Every insurer issuing a group policy for delivery in this state [which] THAT provides medical, major-medical or similar comprehen- sive-type coverage [must] SHALL provide coverage for the provision of preventive and primary care services. (B) In SUBPARAGRAPHS (A), (C) AND (D) OF this paragraph, preventive and primary care services means the following services rendered to a [dependent] COVERED child of an insured from the date of birth through the attainment of nineteen years of age: (i) an initial hospital check-up and well-child visits scheduled in accordance with the prevailing clinical standards of a national associ- ation of pediatric physicians designated by the commissioner of health (except for any standard that would limit the specialty or forum of licensure of the practitioner providing the service other than the limits under state law). Coverage for such services rendered shall be provided only to the extent that such services are provided by or under the supervision of a physician, or other professional licensed under article one hundred thirty-nine of the education law whose scope of practice pursuant to such law includes the authority to provide the specified services. Coverage shall be provided for such services rendered in a hospital, as defined in section twenty-eight hundred one of the public health law, or in an office of a physician or other professional licensed under article one hundred thirty-nine of the education law whose scope of practice pursuant to such law includes the authority to provide the specified services; (ii) at each visit, services in accordance with the prevailing clin- ical standards of such designated association, including a medical history, a complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests which tests are ordered at the time of the visit and performed in the practitioner's office, as authorized by law, or in a clinical laborato- ry; and
(iii) necessary immunizations, as determined by the superintendent in consultation with the commissioner of health, consisting of at least adequate dosages of vaccine against diphtheria, pertussis, tetanus, polio, measles, rubella, mumps, haemophilus influenzae type b and hepa- titis b, which meet the standards approved by the United States public health service for such biological products. (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS PARAGRAPH shall not be subject to annual deductibles [and/or] OR coinsu- rance. (D) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS PARAGRAPH shall not restrict or eliminate existing coverage provided by the policy. (E) IN ADDITION TO SUBPARAGRAPH (A), (B), (C) OR (D) OF THIS PARA- GRAPH, EVERY GROUP POLICY THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (G) OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING PREVEN- TIVE CARE AND SCREENINGS FOR INSUREDS, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (I) EVIDENCE-BASED ITEMS OR SERVICES FOR PREVENTIVE CARE AND SCREEN- INGS THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMEN- DATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; (II) IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI- SORY COMMITTEE ON IMMUNIZATION PRACTICES OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED; (III) WITH RESPECT TO CHILDREN, INCLUDING INFANTS AND ADOLESCENTS, EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS PROVIDED FOR IN COMPRE- HENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMIN- ISTRATION; AND (IV) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS NOT DESCRIBED IN ITEM (I) OF THIS SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (F) THE REQUIREMENTS OF THIS PARAGRAPH SHALL ALSO BE APPLICABLE TO A BLANKET POLICY OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE COVER- ING STUDENTS PURSUANT TO SUBPARAGRAPH (C) OF PARAGRAPH THREE OF SUBSECTION (A) OF SECTION FOUR THOUSAND TWO HUNDRED THIRTY-SEVEN OF THIS CHAPTER. (G) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN- TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 16. Paragraph 11 of subsection (l) of section 3221 of the insurance law, as amended by chapter 554 of the laws of 2002, is amended to read as follows: (11) (A) Every insurer delivering a group or blanket policy or issuing a group or blanket policy for delivery in this state [which] THAT provides coverage for hospital, surgical or medical care shall provide the following coverage for mammography screening for occult breast cancer: (i) upon the recommendation of a physician, a mammogram at any age for covered persons having a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer; (ii) a single baseline mammogram for covered persons aged thirty-five through thirty-nine, inclusive; and (iii) an annual mammogram for covered persons aged forty and older.
(B) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (C) OF THIS PARAGRAPH may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. (C) For purposes OF SUBPARAGRAPHS (A) AND (B) of this paragraph, mammography screening means an X-ray examination of the breast using dedicated equipment, including X-ray tube, filter, compression device, screens, films and cassettes, with an average glandular radiation dose less than 0.5 rem per view per breast. (D) IN ADDITION TO SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH, EVERY GROUP OR BLANKET POLICY THAT PROVIDES COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (E) OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING MAMMOGRAPHY SCREENING SERVICES, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (I) EVIDENCE-BASED ITEMS OR SERVICES FOR MAMMOGRAPHY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (II) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS FOR MAMMOGRAPHY NOT DESCRIBED IN ITEM (I) OF THIS SUBPARA- GRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN- TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 17. Paragraph 14 of subsection (l) of section 3221 of the insurance law, as amended by chapter 554 of the laws of 2002, is amended to read as follows: (14) (A) Every group or blanket policy delivered or issued for deliv- ery in this state [which] THAT provides hospital, surgical or medical coverage shall provide coverage for an annual cervical cytology screen- ing for cervical cancer and its precursor states for women aged eighteen and older. (B) For purposes OF SUBPARAGRAPHS (A) AND (C) of this paragraph, cervical cytology screening shall include an annual pelvic examination, collection and preparation of a Pap smear, and laboratory and diagnostic services provided in connection with examining and evaluating the Pap smear. (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS PARAGRAPH may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. (D) IN ADDITION TO SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH, EVERY GROUP OR BLANKET POLICY THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARA- GRAPH (E) OF THIS PARAGRAPH, SHALL PROVIDE COVERAGE FOR THE FOLLOWING CERVICAL CYTOLOGY SCREENING SERVICES, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (I) EVIDENCE-BASED ITEMS OR SERVICES FOR CERVICAL CYTOLOGY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (II) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS FOR CERVICAL CYTOLOGY NOT DESCRIBED IN ITEM (I) OF THIS
SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAIN- TAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 18. Subparagraph (E) of paragraph 15 of subsection (l) of section 3221 of the insurance law, as added by chapter 506 of the laws of 2001, is amended to read as follows: (E) As used in this paragraph: (i) "Prehospital emergency medical services" means the prompt evalu- ation and treatment of an emergency medical condition, and/or non-air- borne transportation of the patient to a hospital, provided however, where the patient utilizes non-air-borne emergency transportation pursu- ant to this paragraph, reimbursement [will] SHALL be based on whether a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of such transportation to result in [(1)] (I) placing the health of the person affected with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; [(2)] (II) serious impairment to such person's bodily functions; [(3)] (III) serious dysfunction of any bodily organ or part of such person; [or (4)] (IV) serious disfigurement of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. (ii) "Emergency condition" means a medical or behavioral condition[, the onset of which is sudden,] that manifests itself by ACUTE symptoms of sufficient severity, including severe pain, SUCH that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in [(1)] (I) placing the health of the person afflicted with such condi- tion in serious jeopardy, or in the case of a behavioral condition plac- ing the health of such person or others in serious jeopardy; [(2)] (II) serious impairment to such person's bodily functions; ([3)] (III) seri- ous dysfunction of any bodily organ or part of such person; [or (4)] (IV) serious disfigurement of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. S 19. Subsection (m) of section 3221 of the insurance law is amended by adding a new paragraph 8 to read as follows: (8) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (F) OF SECTION FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER. S 20. Subsection (p) of section 3221 of the insurance law is amended by adding a new paragraph 6 to read as follows: (6) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (F) OF SECTION FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER. S 21. Subsection (q) of section 3221 of the insurance law is amended by adding a new paragraph 7 to read as follows: (7) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (F) OF SECTION FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER.
S 22. Paragraphs 1 and 2 of subsection (r) of section 3221 of the insurance law, as added by chapter 240 of the laws of 2009, are amended to read as follows: (1) As used in this subsection, ["dependent child"] "CHILD" means an unmarried child through age twenty-nine of an employee or member insured under a group policy OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE, regardless of financial dependence, who is not insured by or eligible for coverage under any [employee] EMPLOYER health benefit plan as an employee or member, whether insured or self-insured, and who lives, works or resides in New York state or the service area of the insurer and who is not covered under title XVIII of the United States Social Security Act (Medicare). (2) In addition to the conversion privilege afforded by subsection (e) of this section and the continuation privilege afforded by subsection (m) of this section, every group policy delivered or issued for delivery in this state that provides hospital, [surgical or medical coverage] MEDICAL OR SURGICAL EXPENSE INSURANCE COVERAGE for other than specific diseases or accidents only, and which provides [dependent] coverage OF A CHILD that terminates at a specified age, shall, upon application of the employee, member or [dependent] child, as set forth in [subparagraphs (B) or (C)] SUBPARAGRAPH (B) of this paragraph, provide coverage to the [dependent] child after that specified age and through age twenty-nine without evidence of insurability, subject to all of the terms and condi- tions of the group policy and the following: (A) An employer shall not be required to pay all or part of the cost of coverage for a [dependent] child provided pursuant to this subsection; (B) An employee, member or [dependent] child who wishes to elect continuation of coverage pursuant to this subsection shall request the continuation in writing: (i) within sixty days following the date coverage would otherwise terminate due to reaching the specified age set forth in the group poli- cy; (ii) within sixty days after meeting the requirements for [dependent] child status set forth in paragraph one of this subsection when coverage for the [dependent] child previously terminated; or (iii) during an annual thirty-day open enrollment period, as described in the policy; (C) [For twelve months after the effective date of this subsection, an employee, member or dependent child may elect prospective coverage under this subsection for a dependent child whose coverage terminated under the terms of the group policy prior to the initial effective date of this subsection; (D)] An employee, member or [dependent] child electing continuation as described in this subsection shall pay to the group policyholder or employer, but not more frequently than on a monthly basis in advance, the amount of the required premium payment on the due date of each payment. The written election of continuation, together with the first premium payment required to establish premium payment on a monthly basis in advance, shall be given to the group policyholder or employer within the time periods set forth in [subparagraphs (B) and (C)] SUBPARAGRAPH (B) of this paragraph. Any premium received within the thirty-day period after the due date shall be considered timely; [(E)] (D) For any [dependent] child electing coverage within sixty days of the date the [dependent] child would otherwise lose coverage due to reaching a specified age, the effective date of the continuation
coverage shall be the date coverage would have otherwise terminated. For any [dependent] child electing to resume coverage during an annual open enrollment period [or during the twelve-month initial open enrollment period described in subparagraph (C) of this paragraph], the effective date of the continuation coverage shall be prospective no later than thirty days after the election and payment of first premium; [(F)] (E) Coverage for a [dependent] child pursuant to this subsection shall consist of coverage that is identical to the coverage provided to the employee or member parent. If coverage is modified under the policy for any group of similarly situated employees or members, then the coverage shall also be modified in the same manner for any [dependent] child; [(G)] (F) Coverage shall terminate on the first to occur of the following: (i) the date the [dependent] child no longer meets the requirements of paragraph one of this subsection; (ii) the end of the period for which premium payments were made, if there is a failure to make payment of a required premium payment within the period of grace described in subparagraph [(D)] (C) of this para- graph; or (iii) the date on which the group policy is terminated and not replaced by coverage under another group policy; and [(H)] (G) The insurer shall provide written notification of the continuation privilege described in this subsection and the time period in which to request continuation to the employee or member: (i) in each certificate of coverage; AND (ii) at least sixty days prior to termination at the specified age as provided in the policy[; and (iii) within thirty days of the effective date of this subsection, with respect to information concerning a dependent child's opportunity, for twelve months after the effective date of this subsection, to make a written election to obtain coverage under a policy pursuant to subpara- graph (C) of this paragraph]. S 23. Section 3232 of the insurance law is amended by adding four new subsections (f), (g), (h) and (i) to read as follows: (F) WITH RESPECT TO AN INDIVIDUAL UNDER AGE NINETEEN, AN INSURER MAY NOT IMPOSE ANY PRE-EXISTING CONDITION EXCLUSION IN AN INDIVIDUAL OR GROUP POLICY OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE PURSUANT TO THE REQUIREMENTS OF SECTION 2704 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3, AS MADE EFFECTIVE BY SECTION 1255(2) OF THE AFFORDABLE CARE ACT, EXCEPT FOR AN INDIVIDUAL UNDER AGE NINETEEN COVERED UNDER AN INDIVIDUAL POLICY OF HOSPITAL, MEDICAL, SURGI- CAL OR PRESCRIPTION DRUG EXPENSE INSURANCE THAT IS A GRANDFATHERED HEALTH PLAN. (G) BEGINNING JANUARY FIRST, TWO THOUSAND FOURTEEN, PURSUANT TO SECTION 2704 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3, AN INSURER MAY NOT IMPOSE ANY PRE-EXISTING CONDITION EXCLUSION IN AN INDI- VIDUAL OR GROUP POLICY OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE EXCEPT IN AN INDIVIDUAL POLICY THAT IS A GRANDFA- THERED HEALTH PLAN. (H) THE REQUIREMENTS OF SUBSECTIONS (F) AND (G) OF THIS SECTION SHALL ALSO BE APPLICABLE TO A BLANKET POLICY OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE. (I) FOR PURPOSES OF SUBSECTIONS (F) AND (G) OF THIS SECTION, "GRANDFA- THERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS
LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 24. Paragraphs 1 and 2 of subsection (f) of section 4235 of the insurance law, paragraph 1 as amended by chapter 240 of the laws of 2009, and paragraph 2 as amended by chapter 312 of the laws of 2002, are amended to read as follows: (1) (A) Any policy of group accident, group health or group accident and health insurance may include provisions for the payment by the insurer of benefits for expenses incurred on account of hospital, medical or surgical care or physical and occupational therapy by licensed physical and occupational therapists upon the prescription or referral of a physician for the employee or other member of the insured group, [his] THE EMPLOYEE'S OR MEMBER'S spouse, [his] THE EMPLOYEE'S OR MEMBER'S child or children, or other persons chiefly dependent upon [him] THE EMPLOYEE OR MEMBER for support and maintenance; provided that: (I) A POLICY OF HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE THAT PROVIDES COVERAGE FOR CHILDREN SHALL PROVIDE SUCH COVERAGE TO A MARRIED OR UNMARRIED CHILD UNTIL ATTAINMENT OF AGE TWEN- TY-SIX, WITHOUT REGARD TO FINANCIAL DEPENDENCE, RESIDENCY WITH THE EMPLOYEE OR MEMBER, STUDENT STATUS, OR EMPLOYMENT, EXCEPT A POLICY THAT IS A GRANDFATHERED HEALTH PLAN MAY, FOR PLAN YEARS BEGINNING BEFORE JANUARY FIRST, TWO THOUSAND FOURTEEN, EXCLUDE COVERAGE OF AN ADULT CHILD UNDER AGE TWENTY-SIX WHO IS ELIGIBLE TO ENROLL IN AN EMPLOYER-SPONSORED HEALTH PLAN OTHER THAN A GROUP HEALTH PLAN OF A PARENT. FOR PURPOSES OF THIS ITEM, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E); AND (II) a policy under which coverage [of a dependent of an employee or other member of the insured group] terminates at a specified age shall not so terminate with respect to an unmarried child who is incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation, as defined in the mental hygiene law, or physical handicap and who became so incapable prior to attainment of the age at which [dependent] coverage would otherwise terminate and who is chiefly dependent upon such employee or member for support and mainte- nance, while the insurance of the employee or member remains in force and the [dependent] CHILD remains in such condition, if the insured employee or member has within thirty-one days of such [dependent's] CHILD'S attainment of the termination age submitted proof of such [dependent's] CHILD'S incapacity as described herein. (B) In addition to the requirements of subparagraph (A) of this para- graph, every insurer issuing a group policy OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE pursuant to this section that provides cover- age for [dependent] children, must make available and if requested by the policyholder, extend coverage under the policy to an unmarried child through age twenty-nine, without regard to financial dependence who is not insured by or eligible for coverage under any employer health bene- fit plan as an employee or member, whether insured or self-insured, and who lives, works or resides in New York state or the service area of the insurer. Such coverage shall be made available at the inception of all new policies and with respect to all other policies at any anniversary date. Written notice of the availability of such coverage shall be delivered to the policyholder prior to the inception of such group poli- cy and annually thereafter.
(2) Notwithstanding any rule, regulation or law to the contrary, any family coverage available under this article shall provide that coverage of newborn infants, including newly born infants adopted by the insured or subscriber if such insured or subscriber takes physical custody of the infant upon such infant's release from the hospital and files a petition pursuant to section one hundred fifteen-c of the domestic relations law within thirty days of birth; and provided further that no notice of revocation to the adoption has been filed pursuant to section one hundred fifteen-b of the domestic relations law and consent to the adoption has not been revoked, shall be effective from the moment of birth for injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities including premature birth, except that in cases of adoption, coverage of the initial hospital stay shall not be required where a birth parent has insurance coverage available for the infant's care. In the case of indi- vidual coverage the insurer must also permit the person to whom the certificate is issued to elect such coverage of newborn infants from the moment of birth. If notification and/or payment of an additional premium or contribution is required to make coverage effective for a newborn infant, the coverage may provide that such notice and/or payment be made within no less than thirty days of the day of birth to make coverage effective from the moment of birth. This election shall not be required in the case of student insurance or where the group's plan does not provide coverage for [dependent] children. S 25. Paragraph 2 of subsection (a) of section 4303 of the insurance law, as added by chapter 705 of the laws of 1996, is amended to read as follows: (2) (A) For services to treat an emergency condition in hospital facilities[.]: (I) WITHOUT THE NEED FOR ANY PRIOR AUTHORIZATION DETERMINATION; (II) REGARDLESS OF WHETHER THE HEALTH CARE PROVIDER FURNISHING SUCH SERVICES IS A PARTICIPATING PROVIDER WITH RESPECT TO SUCH SERVICES; (III) IF THE EMERGENCY SERVICES ARE PROVIDED BY A NON-PARTICIPATING PROVIDER, WITHOUT IMPOSING ANY ADMINISTRATIVE REQUIREMENT OR LIMITATION ON COVERAGE THAT IS MORE RESTRICTIVE THAN THE REQUIREMENTS OR LIMITA- TIONS THAT APPLY TO EMERGENCY SERVICES RECEIVED FROM PARTICIPATING PROVIDERS; AND (IV) IF THE EMERGENCY SERVICES ARE PROVIDED BY A NON-PARTICIPATING PROVIDER, THE COST-SHARING REQUIREMENT (EXPRESSED AS A COPAYMENT OR COINSURANCE) SHALL BE THE SAME REQUIREMENT THAT WOULD APPLY IF SUCH SERVICES WERE PROVIDED BY A PARTICIPATING PROVIDER. (B) ANY REQUIREMENTS OF SECTION 2719A(B) OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG19A(B) AND REGULATIONS THEREUNDER THAT EXCEED THE REQUIREMENTS OF THIS PARAGRAPH WITH RESPECT TO COVERAGE OF EMERGENCY SERVICES SHALL BE APPLICABLE TO EVERY CONTRACT SUBJECT TO THIS PARA- GRAPH. (C) For the purpose of this provision, "emergency condition" means a medical or behavioral condition[, the onset of which is sudden,] that manifests itself by ACUTE symptoms of sufficient severity, including severe pain, SUCH that a prudent layperson, possessing an average know- ledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in [(A)] (I) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy[, or (B)]; (II) serious impairment to such person's bodily functions; [(C)] (III) serious dysfunction of any bodily
organ or part of such person; [or (D)] (IV) serious disfigurement of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. (D) FOR THE PURPOSE OF THIS PROVISION, "EMERGENCY SERVICES" MEANS, WITH RESPECT TO AN EMERGENCY CONDITION: (I) A MEDICAL SCREENING EXAMINA- TION AS REQUIRED UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, WHICH IS WITHIN THE CAPABILITY OF THE EMERGENCY DEPART- MENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY AVAILABLE TO THE EMERGENCY DEPARTMENT TO EVALUATE SUCH EMERGENCY MEDICAL CONDITION; AND (II) WITHIN THE CAPABILITIES OF THE STAFF AND FACILITIES AVAILABLE AT THE HOSPITAL, SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT AS ARE REQUIRED UNDER SECTION 1867 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, TO STABILIZE THE PATIENT. (E) FOR THE PURPOSE OF THIS PROVISION, "TO STABILIZE" MEANS, WITH RESPECT TO AN EMERGENCY CONDITION, TO PROVIDE SUCH MEDICAL TREATMENT OF THE CONDITION AS MAY BE NECESSARY TO ASSURE, WITHIN REASONABLE MEDICAL PROBABILITY, THAT NO MATERIAL DETERIORATION OF THE CONDITION IS LIKELY TO RESULT FROM OR OCCUR DURING THE TRANSFER OF THE SUBSCRIBER FROM A FACILITY OR TO DELIVER A NEWBORN CHILD (INCLUDING THE PLACENTA). S 26. Subsection (j) of section 4303 of the insurance law, as amended by chapter 728 of the laws of 1993, is amended to read as follows: (j)(1) A health service corporation or medical expense indemnity corporation [which] THAT provides medical, major-medical or similar comprehensive-type coverage [must] SHALL provide coverage for the provision of preventive and primary care services. (2) For purposes OF THIS PARAGRAPH AND PARAGRAPH ONE of this subsection, preventive and primary care services shall mean the follow- ing services rendered to a [dependent] COVERED child of a subscriber from the date of birth through the attainment of nineteen years of age: [(i)] (A) an initial hospital check-up and well-child visits scheduled in accordance with the prevailing clinical standards of a national asso- ciation of pediatric physicians designated by the commissioner of health (except for any standard that would limit the specialty or forum of licensure of the practitioner providing the service other than the limits under state law). Coverage for such services rendered shall be provided only to the extent that such services are provided by or under the supervision of a physician, or other professional licensed under article one hundred thirty-nine of the education law whose scope of practice pursuant to such law includes the authority to provide the specified services. Coverage shall be provided for such services rendered in a hospital, as defined in section twenty-eight hundred one of the public health law, or in an office of a physician or other professional licensed under article one hundred thirty-nine of the education law whose scope of practice pursuant to such law includes the authority to provide the specified services, [(ii)] (B) at each visit, services in accordance with the prevailing clinical standards of such designated association, including a medical history, a complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests which tests are ordered at the time of the visit and performed in the practitioner's office, as authorized by law, or in a clinical laborato- ry, and [(iii)] (C) necessary immunizations, as determined by the superinten- dent in consultation with the commissioner of health, consisting of at least adequate dosages of vaccine against diphtheria, pertussis, teta- nus, polio, measles, rubella, mumps, haemophilus influenzae type b and
hepatitis b, which meet the standards approved by the United States public health service for such biological products. (D) Such coverage REQUIRED PURSUANT TO THIS PARAGRAPH AND PARAGRAPH ONE OF THIS SUBSECTION shall not be subject to annual deductibles [and/or] OR coinsurance. (E) Such coverage REQUIRED PURSUANT TO THIS PARAGRAPH AND PARAGRAPH ONE OF THIS SUBSECTION shall not restrict or eliminate existing coverage provided by the contract. (3) IN ADDITION TO PARAGRAPH ONE OR TWO OF THIS SUBSECTION, EVERY CONTRACT THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE COVERAGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER PARAGRAPH FOUR OF THIS SUBSECTION, SHALL PROVIDE COVERAGE FOR THE FOLLOWING PREVENTIVE CARE AND SCREENINGS FOR SUBSCRIBERS, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (A) EVIDENCE-BASED ITEMS OR SERVICES FOR PREVENTIVE CARE AND SCREEN- INGS THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMEN- DATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; (B) IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI- SORY COMMITTEE ON IMMUNIZATION PRACTICES OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED; (C) WITH RESPECT TO CHILDREN, INCLUDING INFANTS AND ADOLESCENTS, EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS PROVIDED FOR IN COMPRE- HENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMIN- ISTRATION; AND (D) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN- INGS NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS PARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (4) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 27. Subsection (p) of section 4303 of the insurance law, as amended by chapter 554 of the laws of 2002, is amended to read as follows: (p) (1) A medical expense indemnity corporation, a hospital service corporation or a health service corporation [which] THAT provides cover- age for hospital, surgical or medical care shall provide the following coverage for mammography screening for occult breast cancer: (A) upon the recommendation of a physician, a mammogram at any age for covered persons having a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer; (B) a single baseline mammogram for covered persons aged thirty-five through thirty-nine, inclusive; and (C) an annual mammogram for covered persons aged forty and older. (D) The coverage required in this paragraph OR PARAGRAPH TWO OF THIS SUBSECTION may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given [policy] CONTRACT. (2) [In no event shall coverage pursuant to this section include more than one annual screening. (3)] For purposes OF PARAGRAPH ONE of this subsection, mammography screening means an X-ray examination of the breast using dedicated equipment, including X-ray tube, filter, compression device, screens, films and cassettes, with an average glandular radiation dose less than 0.5 rem per view per breast.
(3) IN ADDITION TO PARAGRAPH ONE OR TWO OF THIS SUBSECTION, EVERY CONTRACT THAT PROVIDES COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER PARAGRAPH FOUR OF THIS SUBSECTION, SHALL PROVIDE COVERAGE FOR THE FOLLOWING MAMMOGRAPHY SCREEN- ING SERVICES, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCT- IBLES OR COINSURANCE: (A) EVIDENCE-BASED ITEMS OR SERVICES FOR MAMMOGRAPHY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (B) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN- INGS FOR MAMMOGRAPHY NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS PARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (4) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 28. Subsection (t) of section 4303 of the insurance law, as amended by chapter 43 of the laws of 1993 and paragraph 1 as amended by chapter 554 of the laws of 2002, is amended to read as follows: (t) (1) A medical expense indemnity corporation, a hospital service corporation or a health service corporation [which] THAT provides cover- age for hospital, surgical, or medical care shall provide coverage for an annual cervical cytology screening for cervical cancer and its precursor states for women aged eighteen and older. Such coverage REQUIRED BY THIS PARAGRAPH may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given contract. (2) For purposes OF PARAGRAPH ONE of this subsection, cervical cytolo- gy screening shall include an annual pelvic examination, collection and preparation of a Pap smear, and laboratory and diagnostic services provided in connection with examining and evaluating the Pap smear. (3) IN ADDITION TO PARAGRAPH ONE OR TWO OF THIS SUBSECTION, EVERY CONTRACT THAT PROVIDES COVERAGE FOR HOSPITAL, SURGICAL OR MEDICAL CARE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER PARAGRAPH FOUR OF THIS SUBSECTION, SHALL PROVIDE COVERAGE FOR THE FOLLOWING CERVICAL CYTOLOGY SCREENING SERVICES, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (A) EVIDENCE-BASED ITEMS OR SERVICES FOR CERVICAL CYTOLOGY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (B) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN- INGS FOR CERVICAL CYTOLOGY NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS PARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (4) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 29. Paragraph 5 of subsection (aa) of section 4303 of the insurance law, as added by chapter 506 of the laws of 2001, is amended to read as follows: (5) As used in this subsection:
(A) "Prehospital emergency medical services" means the prompt evalu- ation and treatment of an emergency medical condition, and/or non-air- borne transportation of the patient to a hospital; provided however, where the patient utilizes non-air-borne emergency transportation pursu- ant to this subsection, reimbursement [will] SHALL be based on whether a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of such transportation to result in (i) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; (ii) serious impairment to such person's bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; [or] (iv) seri- ous disfigurement of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. (B) "Emergency condition" means a medical or behavioral condition[, the onset of which is sudden,] that manifests itself by ACUTE symptoms of sufficient severity, including severe pain, SUCH that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (ii) serious impairment to such person's bodily functions; (iii) serious dysfunction of any bodily organ or part of such person; [or] (iv) serious disfigure- ment of such person; OR (V) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. S 30. Subsection (bb) of section 4303 of the insurance law, as added by chapter 554 of the laws of 2002, is amended to read as follows: (bb) A health service corporation or a medical service expense indem- nity corporation [which] THAT provides major medical or similar compre- hensive-type coverage shall provide such coverage for bone mineral density measurements or tests, and if such contract otherwise includes coverage for prescription drugs, drugs and devices approved by the federal food and drug administration or generic equivalents as approved substitutes. In determining appropriate coverage provided by [this para- graph] PARAGRAPHS ONE, TWO AND THREE OF THIS SUBSECTION, the insurer or health maintenance organization shall adopt standards [which] THAT include the criteria of the federal [medicare] MEDICARE program and the criteria of the national institutes of health for the detection of osteoporosis, provided that such coverage shall be further determined as follows: (1) For purposes OF PARAGRAPHS TWO AND THREE of this subsection, bone mineral density measurements or tests, drugs and devices shall include those covered under the criteria of the federal [medicare] MEDICARE program as well as those in accordance with the criteria of the national institutes of health, including, as consistent with such criteria, dual- energy x-ray absorptiometry. (2) For purposes OF PARAGRAPHS ONE AND THREE of this subsection, bone mineral density measurements or tests, drugs and devices shall be covered for individuals meeting the criteria for coverage, consistent with the criteria under the federal [medicare] MEDICARE program or the criteria of the national institutes of health; provided that, to the extent consistent with such criteria, individuals qualifying for cover- age shall, at a minimum, include individuals: (i) previously diagnosed as having osteoporosis or having a family history of osteoporosis; or
(ii) with symptoms or conditions indicative of the presence, or the significant risk, of osteoporosis; or (iii) on a prescribed drug regimen posing a significant risk of osteo- porosis; or (iv) with lifestyle factors to such a degree as posing a significant risk of osteoporosis; or (v) with such age, gender and/or other physiological characteristics which pose a significant risk for osteoporosis. (3) Such coverage REQUIRED PURSUANT TO PARAGRAPH ONE OR TWO OF THIS SUBSECTION may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. (4) IN ADDITION TO PARAGRAPH ONE, TWO OR THREE OF THIS SUBSECTION, EVERY CONTRACT THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL CARE COVER- AGE, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER PARAGRAPH FIVE OF THIS SUBSECTION, SHALL PROVIDE COVERAGE FOR THE FOLLOWING ITEMS OR SERVICES FOR BONE MINERAL DENSITY, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (A) EVIDENCE-BASED ITEMS OR SERVICES FOR BONE MINERAL DENSITY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (B) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN- INGS FOR BONE MINERAL DENSITY NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS PARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (5) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 31. Paragraphs 1 and 3 of subsection (d) of section 4304 of the insurance law, paragraph 1 as amended by chapter 240 of the laws of 2009 and paragraph 3 as added by chapter 93 of the laws of 1989, are amended to read as follows: (1) (A) No contract issued pursuant to this section shall entitle more than one person to benefits except that a contract issued and marked as a "family contract" may provide that benefits will be furnished to [a husband and wife, or husband, wife and their dependent child or chil- dren, or] THE CONTRACT HOLDER, SPOUSE, DEPENDENT CHILD OR CHILDREN, OR OTHER PERSON CHIEFLY DEPENDENT UPON THE CONTRACT HOLDER PROVIDED THAT: (I) A "FAMILY CONTRACT" MAY PROVIDE COVERAGE TO any child or children not over nineteen years of age, provided that an unmarried student at an accredited institution of learning may be considered a dependent until [he] THE CHILD becomes twenty-three years of age, AND provided ALSO that the coverage of any such "family contract" may include, at the option of the [insurer] CORPORATION, any unmarried child until attaining age twen- ty-five[, and provided also that the]. HOWEVER, A "FAMILY CONTRACT" OF HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE THAT PROVIDES COVERAGE FOR DEPENDENT CHILDREN SHALL PROVIDE SUCH COVERAGE TO A MARRIED OR UNMARRIED CHILD UNTIL ATTAINMENT OF AGE TWENTY-SIX WITHOUT REGARD TO FINANCIAL DEPENDENCE, RESIDENCY WITH THE CONTRACT HOLDER, STUDENT STATUS, OR EMPLOYMENT. (II) THE coverage of any such "family contract" shall include any other unmarried child, regardless of age, who is incapable of self-sus- taining employment by reason of mental illness, developmental disabili- ty, mental retardation, as defined in the mental hygiene law, or phys-
ical handicap and who became so incapable prior to attainment of the age at which [dependent] coverage would otherwise terminate[, so that such child may be considered a dependent]. (B) In addition to the requirements of subparagraph (A) of this para- graph, every corporation issuing a contract OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE that provides coverage for [dependent] chil- dren must make available and if requested by the contractholder, extend coverage under the contract to an unmarried child through age twenty- nine, without regard to financial dependence who is not insured by or eligible for coverage under any [employee] EMPLOYER health benefit plan as an employee or member, whether insured or self-insured, and who lives, works or resides in New York state or the service area of the corporation. Such coverage shall be made available at the inception of all new contracts, [at the first anniversary date of a policy following the effective date of this subparagraph,] and for group remittance contracts at any anniversary date. Written notice of the availability of such coverage shall be delivered to the contractholder prior to the inception of such [group] contract, [thirty days prior to the first anniversary date of a policy following the effective date of this subparagraph,] and for group remittance contracts annually thereafter. (C) Notwithstanding any rule, regulation or law to the contrary, any "family contract" shall provide that coverage of newborn infants, including newly born infants adopted by the [insured or] subscriber if such [insured or] subscriber takes physical custody of the infant upon such infant's release from the hospital and files a petition pursuant to section one hundred fifteen-c of the domestic relations law within thir- ty days of birth; and provided further that no notice of revocation to the adoption has been filed pursuant to section one hundred fifteen-b of the domestic relations law and consent to the adoption has not been revoked, shall be effective from the moment of birth for injury or sick- ness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities including premature birth, except that in cases of adoption, coverage of the initial hospital stay shall not be required where a birth parent has insurance coverage avail- able for the infant's care. This provision regarding coverage of newborn infants shall not apply to two person coverage. In the case of individ- ual or two person coverages the corporation must also permit the person to whom the [policy] CONTRACT is issued to elect such coverage of newborn infants from the moment of birth. If notification and/or payment of an additional premium or contribution is required to make coverage effective for a newborn infant, the coverage may provide that such notice and/or payment be made within no less than thirty days of the day of birth to make coverage effective from the moment of birth. This election shall not be required in the case of student insurance or where the group remitting agent's plan does not provide coverage for [depend- ent] children. (3) Coverage of an unmarried dependent child who is incapable of self- sustaining employment by reason of mental illness, developmental disa- bility or mental retardation, as defined in the mental hygiene law, or physical handicap and who became so incapable prior to attainment of the age at which [dependent] coverage would otherwise terminate and who is chiefly dependent upon the contract holder for support and maintenance, shall not terminate while the [policy] CONTRACT remains in force and the [dependent] CHILD remains in such condition, if the [policyholder] CONTRACT HOLDER has within thirty-one days of such [dependent's] CHILD'S
attainment of the limiting age submitted proof of such [dependent's] CHILD'S incapacity as described herein. S 32. Subsection (e) of section 4304 of the insurance law is amended by adding a new paragraph 5 to read as follows: (5) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (D) OF THIS SECTION. S 33. Paragraph 5 of subsection (k) of section 4304 of the insurance law, as added by chapter 236 of the laws of 2009, is renumbered para- graph 6 and a new paragraph 7 is added to read as follows: (7) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (D) OF THIS SECTION. S 34. Paragraphs 1 and 2 of subsection (m) of section 4304 of the insurance law, as added by chapter 240 of the laws of 2009, are amended to read as follows: (1) As used in this subsection, ["dependent child"] "CHILD" means an unmarried child through age twenty-nine of an employee or member insured under a group remittance contract OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE, regardless of financial dependence, who is not insured by or eligible for coverage under any [employee] EMPLOYER health benefit plan AS AN EMPLOYEE OR MEMBER, whether insured or self-insured, and who lives, works or resides in New York state or the service area of the corporation and who is not covered under title XVIII of the United States Social Security Act (Medicare). (2) In addition to the conversion privilege afforded by subsection (e) of this section and the continuation privilege afforded by subsections (e) and (k) of this section, a hospital service, health service or medical expense corporation or health maintenance organization that provides HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE coverage for which the premiums are paid by the remitting agent of a group that provides [dependent] coverage OF A CHILD that terminates at a specified age shall, upon application of the employee, member or [dependent] child, as set forth in subparagraph (B) [or (C)] of this paragraph, provide coverage to the [dependent] child after that specified age and through age twenty-nine without evidence of insurability, subject to all of the terms and conditions of the group remittance contract and the following: (A) An employer shall not be required to pay all or part of the cost of coverage for a [dependent] child provided pursuant to this subsection; (B) An employee, member or [dependent] child who wishes to elect continuation of coverage pursuant to this subsection shall request the continuation in writing: (i) within sixty days following the date coverage would otherwise terminate due to reaching the specified age set forth in the group contract; (ii) within sixty days after meeting the requirements for [dependent] child status set forth in paragraph one of this subsection when coverage for the [dependent] child previously terminated; or (iii) during an annual thirty-day open enrollment period as described in the contract. (C) [For twelve months after the effective date of this subsection, an employee, member or dependent child may elect prospective continuation coverage under this subsection for a dependent child whose coverage terminated under the terms of the group remittance contract prior to the initial effective date of this subsection;
(D)]
An employee, member or [dependent] child electing continuation as described in this subsection shall pay to the group remitting agent or employer, but not more frequently than on a monthly basis in advance, the amount of the required premium payment on the due date of each payment. The written election of continuation, together with the first premium payment required to establish premium payment on a monthly basis in advance, shall be given to the group remitting agent or employer within the time periods set forth in [subparagraphs (B) and (C)] SUBPAR- AGRAPH (B) of this paragraph. Any premium received within the thirty-day period after the due date shall be considered timely; [(E)] (D) For any [dependent] child electing coverage within sixty days of the date the [dependent] child would otherwise lose coverage due to reaching a specified age, the effective date of the continuation coverage shall be the date coverage would have otherwise terminated. For any [dependent] child electing to resume coverage during an annual open enrollment period [or during the twelve-month initial open enrollment period described in subparagraph (C) of this paragraph], the effective date of the continuation coverage shall be prospective no later than thirty days after the election and payment of first premium; [(F)] (E) Coverage for a [dependent] child pursuant to this subsection shall consist of coverage that is identical to the coverage provided to the employee or member parent. If coverage is modified under the contract for any group of similarly situated employees or members, then the coverage shall also be modified in the same manner for any [depend- ent] child; [(G)] (F) Coverage shall terminate on the first to occur of the following: (i) the date the [dependent] child no longer meets the requirements of paragraph one of this subsection; (ii) the end of the period for which premium payments were made, if there is a failure to make payment of a required premium payment within the period of grace described in subparagraph [(D)] (C) of this para- graph; or (iii) the date on which the group remittance contract is terminated and not replaced by coverage under another group or group remittance contract; and [(H)] (G) The corporation or health maintenance organization shall provide written notification of the continuation privilege described in this subsection and the time period in which to request continuation to the employee or member: (i) in each certificate of coverage; AND (ii) at least sixty days prior to termination at the specified age as provided in the contract[; (iii) within thirty days of the effective date of this subsection, with respect to information concerning a dependent child's opportunity, for twelve months after the effective date of this subsection, to make a written election to obtain coverage under a contract pursuant to subpar- agraph (C) of this paragraph]. S 35. Paragraph 1 of subsection (c) of section 4305 of the insurance law, as amended by chapter 240 of the laws of 2009, is amended to read as follows: (1)(A) Any such contract may provide that benefits will be furnished to a member of a covered group, for [himself] THE MEMBER, [his] THE MEMBER'S spouse, [his] child or children, or other persons chiefly dependent upon [him] THE MEMBER for support and maintenance; provided that:
(I) A CONTRACT OF HOSPITAL, MEDICAL, SURGICAL, OR PRESCRIPTION DRUG EXPENSE INSURANCE THAT PROVIDES COVERAGE FOR CHILDREN SHALL PROVIDE SUCH COVERAGE TO A MARRIED OR UNMARRIED CHILD UNTIL ATTAINMENT OF AGE TWEN- TY-SIX, WITHOUT REGARD TO FINANCIAL DEPENDENCE, RESIDENCY WITH THE MEMBER, STUDENT STATUS, OR EMPLOYMENT, EXCEPT A CONTRACT THAT IS A GRANDFATHERED HEALTH PLAN MAY, FOR PLAN YEARS BEGINNING BEFORE JANUARY FIRST, TWO THOUSAND FOURTEEN, EXCLUDE COVERAGE OF AN ADULT CHILD UNDER AGE TWENTY-SIX WHO IS ELIGIBLE TO ENROLL IN AN EMPLOYER-SPONSORED HEALTH PLAN OTHER THAN A GROUP HEALTH PLAN OF A PARENT. FOR PURPOSES OF THIS ITEM, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPO- RATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E); AND (II) a contract under which coverage [of a dependent of a member] terminates at a specified age shall, with respect to an unmarried child who is incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation, as defined in the mental hygiene law, or physical handicap and who became so incapable prior to attainment of the age at which [dependent] coverage would otherwise terminate and who is chiefly dependent upon such member for support and maintenance, not so terminate while the contract remains in force and the [dependent] CHILD remains in such condition, if the member has within thirty-one days of such [dependent's] CHILD'S attainment of the termination age submitted proof of such [dependent's] CHILD'S inca- pacity as described herein. (B) In addition to the requirements of subparagraph (A) of this para- graph, every corporation issuing a group contract OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE pursuant to this section that provides coverage for [dependent] children, must make available and if requested by the contractholder, extend coverage under that contract to an unmar- ried child through age twenty-nine, without regard to financial depend- ence who is not insured by or eligible for coverage under any [employee] EMPLOYER health benefit plan as an employee or member, whether insured or self-insured, and who lives, works or resides in New York state or the service area of the corporation. Such coverage shall be made avail- able at the inception of all new contracts and with respect to all other contracts at any anniversary date. Written notice of the availability of such coverage shall be delivered to the contractholder prior to the inception of such group contract and annually thereafter. (C) Notwithstanding any rule, regulation or law to the contrary, any contract under which a member elects coverage for [himself, his spouse, his] THE MEMBER, THE MEMBER'S SPOUSE, children or other persons chiefly dependent upon [him] THE MEMBER for support and maintenance shall provide that coverage of newborn infants, including newly born infants adopted by the [insured or subscriber] MEMBER if such [insured or subscriber] MEMBER takes physical custody of the infant upon such infant's release from the hospital and files a petition pursuant to section one hundred fifteen-c of the domestic relations law within thir- ty days of birth; and provided further that no notice of revocation to the adoption has been filed pursuant to section one hundred fifteen-b of the domestic relations law and consent to the adoption has not been revoked, shall be effective from the moment of birth for injury or sick- ness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities including premature birth, except that in cases of adoption, coverage of the initial hospital stay
shall not be required where a birth parent has insurance coverage avail- able for the infant's care. This provision regarding coverage of newborn infants shall not apply to two person coverage. In the case of individ- ual or two person coverages the corporation must also permit the person to whom the certificate is issued to elect such coverage of newborn infants from the moment of birth. If notification and/or payment of an additional premium or contribution is required to make coverage effec- tive for a newborn infant, the coverage may provide that such notice and/or payment be made within no less than thirty days of the day of birth to make coverage effective from the moment of birth. This election shall not be required in the case of student insurance or where the group's plan does not provide coverage for [dependent] children. S 36. Subsection (d) of section 4305 of the insurance law is amended by adding a new paragraph 5 to read as follows: (5) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (C) OF THIS SECTION. S 37. Subsection (e) of section 4305 of the insurance law is amended by adding a new paragraph 9 to read as follows: (9) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (C) OF THIS SECTION. S 38. Subsection (k) of section 4305 of the insurance law is amended by adding a new paragraph 7 to read as follows: (7) FOR PURPOSES OF THIS SUBSECTION, THE TERM "DEPENDENT" SHALL INCLUDE A CHILD AS DESCRIBED IN SUBSECTION (C) OF THIS SECTION. S 39. Subsection (l) of section 4305 of the insurance law, as added by chapter 237 of the laws of 2009, is relettered subsection (m) and para- graphs 1 and 2 of subsection (l) of section 4305 of the insurance law, as added by chapter 240 of the laws of 2009, are amended to read as follows: (1) As used in this subsection, ["dependent child"] "CHILD" means an unmarried child through age twenty-nine of an employee or member insured under a group contract OF HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSUR- ANCE, regardless of financial dependence, who is not insured by or eligible for coverage under any [employee] EMPLOYER health benefit plan AS AN EMPLOYEE OR MEMBER, whether insured or self-insured, and who lives, works or resides in New York state or the service area of the corporation and who is not covered under title XVIII of the United States Social Security Act (Medicare). (2) In addition to the conversion privilege afforded by subsection (d) of this section and the continuation privilege afforded by subsection (e) of this section, a hospital service, health service or medical expense corporation or health maintenance organization that provides group HOSPITAL, MEDICAL OR SURGICAL coverage under which [dependent] coverage OF A CHILD terminates at a specified age shall, upon applica- tion of the employee, member or [dependent] child, as set forth in subparagraph (B) [or (C)] of this paragraph, provide coverage to the [dependent] child after that specified age and through age twenty-nine without evidence of insurability, subject to all of the terms and condi- tions of the group contract and the following: (A) An employer shall not be required to pay all or part of the cost of coverage for a [dependent] child provided pursuant to this subsection; (B) An employee, member or [dependent] child who wishes to elect continuation of coverage pursuant to this subsection shall request the continuation in writing:
(i) within sixty days following the date coverage would otherwise terminate due to reaching the specified age set forth in the group contract; (ii) within sixty days after meeting the requirements for [dependent] child status set forth in paragraph one of this subsection when coverage for the [dependent] child previously terminated; or (iii) during an annual thirty-day open enrollment period, as described in the contract; (C) [For twelve months after the effective date of this subsection, an employee, member or dependent child may elect prospective continuation coverage under this subsection for a dependent child whose coverage terminated under the terms of the group contract prior to the effective date of this subsection; (D)] An employee, member or [dependent] child electing continuation as described in this subsection shall pay to the group contractholder or employer, but not more frequently than on a monthly basis in advance, the amount of the required premium payment on the due date of each payment. The written election of continuation, together with the first premium payment required to establish premium payment on a monthly basis in advance, shall be given to the group contractholder or employer with- in the time periods set forth in [subparagraphs (B) and (C)] SUBPARA- GRAPH (B) of this paragraph. Any premium received within the thirty-day period after the due date shall be considered timely; [(E)] (D) For any [dependent] child electing coverage within sixty days of the date the [dependent] child would otherwise lose coverage due to reaching a specified age, the effective date of the continuation coverage shall be the date coverage would have otherwise terminated. For any [dependent] child electing to resume coverage during an annual open enrollment period [or during the twelve-month initial open enrollment period described in subparagraph (C) of this paragraph], the effective date of the continuation coverage shall be prospective no later than thirty days after the election and payment of first premium; [(F)] (E) Coverage for a [dependent] child pursuant to this subsection shall consist of coverage that is identical to the coverage provided to the employee or member parent. If coverage is modified under the contract for any group of similarly situated employees or members, then the coverage shall also be modified in the same manner for any [depend- ent] child; [(G)] (F) Coverage shall terminate on the first to occur of the following: (i) the date the [dependent] child no longer meets the requirements of paragraph one of this subsection; (ii) the end of the period for which premium payments were made, if there is a failure to make payment of a required premium payment within the period of grace described in subparagraph [(D)] (C) of this para- graph; or (iii) the date on which the group contract is terminated and not replaced by coverage under another group contract; and [(H)] (G) The corporation or health maintenance organization shall provide written notification of the continuation privilege described in this subsection and the time period in which to request continuation to the employee or member: (i) in each certificate of coverage; AND (ii) at least sixty days prior to termination at the specified age as provided in the contract[;
(iii) within thirty days of the effective date of this subsection, with respect to information concerning a dependent child's opportunity, for twelve months after the effective date of this subsection, to make a written election to obtain coverage under a contract pursuant to subpar- agraph (C) of this paragraph]
. S 40. Section 4306-b of the insurance law, as added by chapter 554 of the laws of 2002, is amended to read as follows: S 4306-b. Primary and preventive obstetric and gynecologic care. (a) No corporation subject to the provisions of this article shall by contract, written policy or procedure limit a female subscriber's direct access to primary and preventive obstetric and gynecologic services, INCLUDING ANNUAL EXAMINATIONS, CARE RESULTING FROM SUCH ANNUAL EXAMINA- TIONS, AND TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, from a qualified provider of such services of her choice from within the plan [to less than two examinations annually for such services] or [to] FOR any care related to a pregnancy[. In addition, no corporation subject to this article shall by contract, written policy or procedure limit direct access to primary and preventive obstetric and gynecologic services required as a result of such annual examinations or as a result of an acute gynecologic condition], provided that: (1) such qualified provider discusses such services and treatment plan with the subscriber's primary care practitioner in accordance with the requirements of the corporation; AND (2) SUCH QUALIFIED PROVIDER AGREES TO ADHERE TO THE CORPORATION'S POLICIES AND PROCEDURES, INCLUDING ANY APPLICABLE PROCE- DURES REGARDING REFERRALS AND OBTAINING PRIOR AUTHORIZATION FOR SERVICES OTHER THAN OBSTETRIC AND GYNECOLOGIC SERVICES RENDERED BY SUCH QUALIFIED PROVIDER, AND AGREES TO PROVIDE SERVICES PURSUANT TO A TREATMENT PLAN (IF ANY) APPROVED BY THE CORPORATION. (b) A CORPORATION SHALL TREAT THE PROVISION OF OBSTETRIC AND GYNECO- LOGIC CARE, AND THE ORDERING OF RELATED OBSTETRIC AND GYNECOLOGIC ITEMS AND SERVICES, PURSUANT TO THE DIRECT ACCESS DESCRIBED IN SUBSECTION (A) OF THIS SECTION BY A PARTICIPATING QUALIFIED PROVIDER OF SUCH SERVICES, AS THE AUTHORIZATION OF THE PRIMARY CARE PROVIDER. (C) It shall be the duty of the administrative officer or other person in charge of each corporation subject to the provisions of this article to advise each female subscriber, in writing, of the provisions of this section. S 41. The insurance law is amended by adding a new section 4306-d to read as follows: S 4306-D. CHOICE OF HEALTH CARE PROVIDER. A CORPORATION THAT IS SUBJECT TO THE PROVISIONS OF THIS ARTICLE AND REQUIRES OR PROVIDES FOR DESIGNATION BY A SUBSCRIBER OF A PARTICIPATING PRIMARY CARE PROVIDER SHALL PERMIT THE SUBSCRIBER TO DESIGNATE ANY PARTICIPATING PRIMARY CARE PROVIDER WHO IS AVAILABLE TO ACCEPT SUCH INDIVIDUAL, AND IN THE CASE OF A CHILD, SHALL PERMIT THE SUBSCRIBER TO DESIGNATE A PHYSICIAN (ALLOPATH- IC OR OSTEOPATHIC) WHO SPECIALIZES IN PEDIATRICS AS THE CHILD'S PRIMARY CARE PROVIDER IF SUCH PROVIDER PARTICIPATES IN THE NETWORK OF THE CORPO- RATION. S 42. The insurance law is amended by adding a new section 4306-e to read as follows: S 4306-E. PROHIBITION ON LIFETIME AND ANNUAL LIMITS. (A) A CORPO- RATION SHALL NOT ESTABLISH A LIFETIME LIMIT ON THE DOLLAR AMOUNT OF ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP OR BLANKET CONTRACT OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE. (B) A CORPORATION SHALL NOT ESTABLISH AN ANNUAL LIMIT ON THE DOLLAR AMOUNT OF ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP OR BLANKET
CONTRACT OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE FOR CONTRACT YEARS BEGINNING ON AND AFTER JANUARY ONE, TWO THOUSAND FOURTEEN. (C) FOR CONTRACT YEARS BEGINNING PRIOR TO JANUARY ONE, TWO THOUSAND FOURTEEN, A CORPORATION MAY ESTABLISH RESTRICTED ANNUAL LIMITS ON THE DOLLAR AMOUNT OF ESSENTIAL HEALTH BENEFITS IN AN INDIVIDUAL, GROUP OR BLANKET CONTRACT OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE CONSISTENT WITH SECTION 2711 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-11 OR ANY REGULATIONS THEREUNDER. (D) THE REQUIREMENTS OF SUBSECTIONS (B) AND (C) OF THIS SECTION SHALL NOT BE APPLICABLE TO ANY INDIVIDUAL CONTRACT THAT IS A GRANDFATHERED HEALTH PLAN. FOR PURPOSES OF THIS SECTION, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). (E) FOR PURPOSES OF THIS SECTION, "ESSENTIAL HEALTH BENEFITS" SHALL HAVE THE MEANING ASCRIBED BY SECTION 1302(B) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B). S 43. Section 4318 of the insurance law is amended by adding four new subsections (f), (g), (h) and (i) to read as follows: (F) WITH RESPECT TO AN INDIVIDUAL UNDER AGE NINETEEN, A CORPORATION MAY NOT IMPOSE ANY PRE-EXISTING CONDITION EXCLUSION IN AN INDIVIDUAL OR GROUP CONTRACT OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE PURSUANT TO THE REQUIREMENTS OF SECTION 2704 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3, AS MADE EFFECTIVE BY SECTION 1255(2) OF THE AFFORDABLE CARE ACT, EXCEPT FOR AN INDIVIDUAL UNDER AGE NINETEEN COVERED UNDER AN INDIVIDUAL CONTRACT OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE THAT IS A GRANDFATHERED HEALTH PLAN. (G) BEGINNING JANUARY FIRST, TWO THOUSAND FOURTEEN, PURSUANT TO SECTION 2704 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3, A CORPORATION MAY NOT IMPOSE ANY PRE-EXISTING CONDITION EXCLUSION IN AN INDIVIDUAL OR GROUP CONTRACT OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE EXCEPT IN AN INDIVIDUAL CONTRACT THAT IS A GRANDFATHERED HEALTH PLAN. (H) THE REQUIREMENTS OF SUBSECTIONS (F) AND (G) OF THIS SECTION SHALL ALSO BE APPLICABLE TO A BLANKET CONTRACT OF HOSPITAL, MEDICAL, SURGICAL OR PRESCRIPTION DRUG EXPENSE INSURANCE. (I) FOR PURPOSES OF SUBSECTIONS (F) AND (G) OF THIS SECTION, "GRANDFA- THERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 44. Subsection (c) of section 4321 of the insurance law, as added by chapter 504 of the laws of 1995, is amended to read as follows: (c) The health maintenance organization shall impose a fifteen dollar copayment on all visits to a physician or other provider with the excep- tion of visits for pre-natal and post-natal care [or], well child visits provided pursuant to paragraph two of subsection (j) of section four thousand three hundred three of this article, PREVENTIVE HEALTH SERVICES PROVIDED PURSUANT TO SUBPARAGRAPH (F) OF PARAGRAPH FOUR OF SUBSECTION (B) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-TWO OF THIS ARTICLE, OR ITEMS OR SERVICES FOR BONE MINERAL DENSITY PROVIDED PURSUANT TO SUBPARAGRAPH (D) OF PARAGRAPH TWENTY-SIX OF SUBSECTION (B) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-TWO OF THIS ARTICLE for which no
copayment shall apply. A copayment of fifteen dollars shall be imposed on equipment, supplies and self-management education for the treatment of diabetes. A fifty dollar copayment shall be imposed on emergency services rendered in the emergency room of a hospital; however, this copayment must be waived if hospital admission results. Surgical services shall be subject to a copayment of the lesser of twenty percent of the cost of such services or two hundred dollars per occurrence. A five hundred dollar copayment shall be imposed on inpatient hospital services per continuous hospital confinement. Ambulatory surgical services shall be subject to a facility copayment charge of seventy-five dollars. Coinsurance of ten percent shall apply to visits for the diag- nosis and treatment of mental, nervous or emotional disorders or ailments. S 45. Subparagraphs (D) and (E) of paragraph 4 of subsection (b) of section 4322 of the insurance law, as amended by chapter 554 of the laws of 2002, are amended and a new subparagraph (F) is added to read as follows: (D) mammography screening, as provided in subsection (p) of section four thousand three hundred three of this article; [and] (E) cervical cytology screening as provided in subsection (t) of section four thousand three hundred three of this article[.]; AND (F) FOR A CONTRACT THAT IS NOT A GRANDFATHERED HEALTH PLAN, THE FOLLOWING ADDITIONAL PREVENTIVE HEALTH SERVICES: (I) EVIDENCE-BASED ITEMS OR SERVICES THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVEN- TIVE SERVICES TASK FORCE; (II) IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI- SORY COMMITTEE ON IMMUNIZATION PRACTICES OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED; (III) WITH RESPECT TO CHILDREN, INCLUDING INFANTS AND ADOLESCENTS, EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS PROVIDED FOR IN THE COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION; AND (IV) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS NOT DESCRIBED IN ITEM (I) OF THIS SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (V) FOR PURPOSES OF THIS SUBPARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 46. Paragraph 26 of subsection (b) of section 4322 of the insurance law, as added by chapter 554 of the laws of 2002, is amended to read as follows: (26) Bone mineral density measurements or tests and, if such contract otherwise includes coverage for prescription drugs, drugs and devices approved by the federal food and drug administration or generic equiv- alents as approved substitutes. In determining appropriate coverage provided by SUBPARAGRAPHS (A), (B) AND (C) OF this paragraph, the insurer or health maintenance organiza- tion shall adopt standards [which] THAT include the criteria of the federal [medicare] MEDICARE program and the criteria of the national institutes of health for the detection of osteoporosis, provided that such coverage shall be further determined as follows:
(A) For purposes of SUBPARAGRAPHS (B) AND (C) OF this paragraph, bone mineral density measurements or tests, drugs and devices shall include those covered under the criteria of the federal [medicare] MEDICARE program as well as those in accordance with the criteria, of the national institutes of health, including, as consistent with such crite- ria dual-energy x-ray absorptiometry. (B) For purposes of SUBPARAGRAPHS (A) AND (C) OF this paragraph, bone mineral density measurements or tests, drugs and devices shall be covered for individuals meeting the criteria for coverage consistent with the criteria under the federal [medicare] MEDICARE program or the criteria of the national institutes of health; provided that, to the extent consistent with such criteria, individuals qualifying for cover- age shall at a minimum, include individuals: (i) previously diagnosed as having osteoporosis or having a family history of osteoporosis; or (ii) with symptoms or conditions indicative of the presence, or the significant risk, of osteoporosis; or (iii) on a prescribed drug regimen posing a significant risk of osteo- porosis; or (iv) with lifestyle factors to such a degree as posing a significant risk of osteoporosis; or (v) with such age, gender and/or other physiological characteristics which pose a significant risk for osteoporosis. (C) Such coverage REQUIRED PURSUANT TO SUBPARAGRAPH (A) OR (B) OF THIS PARAGRAPH may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. (D) IN ADDITION TO SUBPARAGRAPH (A), (B) OR (C) OF THIS PARAGRAPH, EXCEPT FOR A GRANDFATHERED HEALTH PLAN UNDER SUBPARAGRAPH (E) OF THIS PARAGRAPH, COVERAGE SHALL BE PROVIDED FOR THE FOLLOWING ITEMS OR SERVICES FOR BONE MINERAL DENSITY, AND SUCH COVERAGE SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE: (I) EVIDENCE-BASED ITEMS OR SERVICES FOR BONE MINERAL DENSITY THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVENTIVE SERVICES TASK FORCE; AND (II) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREENINGS FOR BONE MINERAL DENSITY NOT DESCRIBED IN ITEM (I) OF THIS SUBPARAGRAPH AND AS PROVIDED FOR IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 47. Subsections (c) and (d) of section 4322 of the insurance law, as added by chapter 504 of the laws of 1995, are amended to read as follows: (c) The in-plan benefit system shall impose a ten dollar copayment on all visits to a physician or other provider with the exception of visits for pre-natal and post-natal care [or], well child visits provided pursuant to paragraph two of subsection (j) of section four thousand three hundred three of this article, PREVENTIVE HEALTH SERVICES PROVIDED PURSUANT TO SUBPARAGRAPH (F) OF PARAGRAPH FOUR OF SUBSECTION (B) OF THIS SECTION OR ITEMS OR SERVICES FOR BONE MINERAL DENSITY PROVIDED PURSUANT TO SUBPARAGRAPH (D) OF PARAGRAPH TWENTY-SIX OF SUBSECTION (B) OF THIS SECTION for which no copayment shall apply. A copayment of ten dollars
shall be imposed on equipment, supplies and self-management education for the treatment of diabetes. Coinsurance of ten percent shall apply to visits for the diagnosis and treatment of mental, nervous or emotional disorders or ailments. A thirty-five dollar copayment shall be imposed on emergency services rendered in the emergency room of a hospital; however, this copayment must be waived if hospital admission results. (d) The out-of-plan benefit system shall have an annual deductible established at one thousand dollars per calendar year for an individual and two thousand dollars per year for a family. Coinsurance shall be established at twenty percent with the health maintenance organization or insurer paying eighty percent of the usual, customary and reasonable charges, or eighty percent of the amounts listed on a fee schedule filed with and approved by the superintendent which provides a comparable level of reimbursement. Coinsurance of ten percent shall apply to outpa- tient visits for the diagnosis and treatment of mental, nervous or emotional disorders or ailments. The benefits described in subparagraph (F) of paragraph three and paragraphs seventeen and eighteen of subsection (b) of this section shall not be subject to the deductible or coinsurance. The benefits described in paragraph nine of subsection (b) of this section shall not be subject to the deductible. The out-of-plan out-of-pocket maximum deductible and coinsurance shall be established at three thousand dollars per calendar year for an individual and five thousand dollars per calendar year for a family. The out-of-plan life- time benefit maximum shall be established at five hundred thousand dollars FOR BENEFITS THAT ARE NOT ESSENTIAL HEALTH BENEFITS. A LIFETIME LIMIT ON THE DOLLAR AMOUNT OF ESSENTIAL HEALTH BENEFITS FOR ANY INDIVID- UAL SHALL NOT BE ESTABLISHED. FOR PURPOSES OF THIS SUBSECTION, "ESSEN- TIAL HEALTH BENEFITS" SHALL HAVE THE MEANING ASCRIBED BY SECTION 1302(B) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B). S 48. Paragraphs 13 and 14 of subsection (d) of section 4326 of the insurance law, as added by chapter 1 of the laws of 1999, are amended and a new paragraph 15 is added to read as follows: (13) blood and blood products furnished in connection with surgery or inpatient hospital services; [and] (14) prescription drugs obtained at a participating pharmacy. In addi- tion to providing coverage at a participating pharmacy, health mainte- nance organizations may utilize a mail order prescription drug program. Health maintenance organizations may provide prescription drugs pursuant to a drug formulary; however, health maintenance organizations must implement an appeals process so that the use of non-formulary prescription drugs may be requested by a physician[.]; AND (15) FOR A CONTRACT THAT IS NOT A GRANDFATHERED HEALTH PLAN, THE FOLLOWING ADDITIONAL PREVENTIVE HEALTH SERVICES: (A) EVIDENCE-BASED ITEMS OR SERVICES THAT HAVE IN EFFECT A RATING OF 'A' OR 'B' IN THE CURRENT RECOMMENDATIONS OF THE UNITED STATES PREVEN- TIVE SERVICES TASK FORCE; (B) IMMUNIZATIONS THAT HAVE IN EFFECT A RECOMMENDATION FROM THE ADVI- SORY COMMITTEE ON IMMUNIZATION PRACTICES OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION WITH RESPECT TO THE INDIVIDUAL INVOLVED; (C) WITH RESPECT TO CHILDREN, INCLUDING INFANTS AND ADOLESCENTS, EVIDENCE-INFORMED PREVENTIVE CARE AND SCREENINGS PROVIDED FOR IN THE COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION; AND (D) WITH RESPECT TO WOMEN, SUCH ADDITIONAL PREVENTIVE CARE AND SCREEN- INGS NOT DESCRIBED IN SUBPARAGRAPH (A) OF THIS PARAGRAPH AS PROVIDED FOR
IN COMPREHENSIVE GUIDELINES SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION. (E) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 49. Paragraphs 6 and 7 of subsection (e) of section 4326 of the insurance law, as added by chapter 1 of the laws of 1999, are amended to read as follows: (6) (A) the maximum coverage for prescription drugs IN AN INDIVIDUAL CONTRACT THAT IS A GRANDFATHERED HEALTH PLAN shall be three thousand dollars per individual in a calendar year; and (B) THE MAXIMUM DOLLAR AMOUNT ON COVERAGE FOR PRESCRIPTION DRUGS IN AN INDIVIDUAL CONTRACT THAT IS NOT A GRANDFATHERED HEALTH PLAN OR IN ANY GROUP CONTRACT SHALL BE CONSISTENT WITH SECTION 2711 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-11 OR ANY REGULATIONS THEREUNDER. (C) FOR PURPOSES OF THIS PARAGRAPH, "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E); AND (7) all other services shall have a twenty dollar copayment with the exception of prenatal care which shall have a ten dollar copayment OR PREVENTIVE HEALTH SERVICES PROVIDED PURSUANT TO PARAGRAPH FIFTEEN OF SUBSECTION (D) OF THIS SECTION, FOR WHICH NO COPAYMENT SHALL APPLY. S 50. Subsection (k) of section 4326 of the insurance law, as added by chapter 1 of the laws of 1999, is amended to read as follows: (k) (1) All coverage under a qualifying group health insurance contract or a qualifying individual health insurance contract must be subject to a pre-existing condition limitation provision as set forth in sections three thousand two hundred thirty-two of this chapter and four thousand three hundred eighteen of this article, including the crediting requirements thereunder. The underwriting of such contracts may not involve more than the imposition of a pre-existing condition limitation. HOWEVER, AS PROVIDED IN SECTIONS THREE THOUSAND TWO HUNDRED THIRTY-TWO OF THIS CHAPTER AND FOUR THOUSAND THREE HUNDRED EIGHTEEN OF THIS ARTI- CLE, A CORPORATION SHALL NOT IMPOSE A PRE-EXISTING CONDITION LIMITATION PROVISION ON ANY PERSON UNDER AGE NINETEEN, EXCEPT MAY IMPOSE SUCH A LIMITATION ON THOSE PERSONS COVERED BY A QUALIFYING INDIVIDUAL HEALTH INSURANCE CONTRACT THAT IS A GRANDFATHERED HEALTH PLAN. (2) BEGINNING JANUARY FIRST, TWO THOUSAND FOURTEEN, PURSUANT TO SECTION 2704 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-3, A CORPORATION SHALL NOT IMPOSE ANY PRE-EXISTING CONDITION LIMITATION IN A QUALIFYING GROUP HEALTH INSURANCE CONTRACT OR A QUALIFYING INDIVIDUAL HEALTH INSURANCE CONTRACT EXCEPT MAY IMPOSE SUCH A LIMITATION IN A QUAL- IFYING INDIVIDUAL HEALTH INSURANCE CONTRACT THAT IS A GRANDFATHERED HEALTH PLAN. (3) FOR PURPOSES OF PARAGRAPHS ONE AND TWO OF THIS SUBSECTION, "GRAND- FATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). S 51. Subsection (c) of section 4900 of the insurance law, as added by chapter 705 of the laws of 1996, is amended to read as follows:
(c) "Emergency condition" means a medical or behavioral condition, [the onset of which is sudden,] that manifests itself by ACUTE symptoms of sufficient severity, including severe pain, SUCH that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (1) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; (2) serious impair- ment to such person's bodily functions; (3) serious dysfunction of any bodily organ or part of such person; [or] (4) serious disfigurement of such person; OR (5) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. S 52. Subsection (g-7) of section 4900 of the insurance law, as added by chapter 237 of the laws of 2009, is amended to read as follows: (g-7) "Rare disease" means a [life threatening or disabling] condition or disease that (1)(A) is currently or has been subject to a research study by the National Institutes of Health Rare Diseases Clinical Research Network; or (B) affects fewer than two hundred thousand United States residents per year; and (2) for which there does not exist a standard health service or procedure covered by the health care plan that is more clinically beneficial than the requested health service or treatment. A physician, other than the insured's treating physician, shall certify in writing that the condition is a rare disease as defined in this subsection. The certifying physician shall be a licensed, board- certified or board-eligible physician who specializes in the area of practice appropriate to treat the insured's rare disease. The certif- ication shall provide either: (1) that the insured's rare disease is currently or has been subject to a research study by the National Insti- tutes of Health Rare Diseases Clinical Research Network; or (2) that the insured's rare disease affects fewer than two hundred thousand United States residents per year. The certification shall rely on medical and scientific evidence to support the requested health service or proce- dure, if such evidence exists, and shall include a statement that, based on the physician's credible experience, there is no standard treatment that is likely to be more clinically beneficial to the insured than the requested health service or procedure and the requested health service or procedure is likely to benefit the insured in the treatment of the insured's rare disease and that such benefit to the insured outweighs the risks of such health service or procedure. The certifying physician shall disclose any material financial or professional relationship with the provider of the requested health service or procedure as part of the application for external appeal of denial of a rare disease treatment. If the provision of the requested health service or procedure at a health care facility requires prior approval of an institutional review board, an insured or insured's designee shall also submit such approval as part of the external appeal application. S 53. Subparagraphs (A) and (B) of paragraph 1 of subsection (b) of section 4910 of the insurance law, as added by chapter 586 of the laws of 1998, are amended to read as follows: (A) the insured has had coverage of the health care service, which would otherwise be a covered benefit under a subscriber contract or governmental health benefit program, denied on appeal, in whole or in part, pursuant to title one of this article on the grounds that such health care service [is not medically necessary] DOES NOT MEET THE HEALTH CARE PLAN'S REQUIREMENTS FOR MEDICAL NECESSITY, APPROPRIATENESS,
HEALTH CARE SETTING, LEVEL OF CARE, OR EFFECTIVENESS OF A COVERED BENE- FIT, and (B) the health care plan has rendered a final adverse determination with respect to such health care service or both the plan and the insured have jointly agreed to waive any internal appeal, OR THE INSURED IS DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE ANY INTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19; or S 54. Subparagraphs (A), (B) and (C) of paragraph 2 of subsection (b) of section 4910 of the insurance law, subparagraph (A) as added by chap- ter 586 of the laws of 1998, and subparagraphs (B) and (C) as amended by chapter 237 of the laws of 2009, are amended to read as follows: (A) the insured has had coverage of a health care service denied on the basis that such service is experimental or investigational, and such denial has been upheld on appeal under [section four thousand nine hundred four] TITLE ONE of this article, or both the plan and the insured have jointly agreed to waive any internal appeal, OR THE INSURED IS DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE ANY INTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19, and (B) the insured's attending physician has certified that the insured has a [life-threatening or disabling] condition or disease (a) for which standard health services or procedures have been ineffective or would be medically inappropriate, or (b) for which there does not exist a more beneficial standard health service or procedure covered by the health care plan, or (c) for which there exists a clinical trial or rare disease treatment, and (C) the insured's attending physician, who must be a licensed, board- certified or board-eligible physician qualified to practice in the area of practice appropriate to treat the insured's [life-threatening or disabling] condition or disease, must have recommended either (a) a health service or procedure (including a pharmaceutical product within the meaning of subparagraph (B) of paragraph two of subsection (e) of section four thousand nine hundred of this article) that, based on two documents from the available medical and scientific evidence, is likely to be more beneficial to the insured than any covered standard health service or procedure or, in the case of a rare disease, based on the physician's certification required by subsection (g-7) of section four thousand nine hundred of this article and such other evidence as the insured, the insured's designee or the insured's attending physician may present, that the requested health service or procedure is likely to benefit the insured in the treatment of the insured's rare disease and that such benefit to the insured outweighs the risks of such health service or procedure; or (b) a clinical trial for which the insured is eligible. Any physician certification provided under this section shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation, and S 55. Subsection (c) of section 4910 of the insurance law, as added by chapter 586 of the laws of 1998, is amended to read as follows: (c) (1) The health care plan may charge the insured a fee of up to [fifty] TWENTY-FIVE dollars per external appeal WITH AN ANNUAL LIMIT ON FILING FEES FOR AN INSURED NOT TO EXCEED SEVENTY-FIVE DOLLARS WITHIN A SINGLE PLAN YEAR; provided that, in the event the external appeal agent overturns the final adverse determination of the plan, such fee shall be refunded to the insured. Notwithstanding the foregoing, the health plan shall not require the enrollee to pay any such fee if the enrollee is a
recipient of medical assistance or is covered by a policy pursuant to title one-A of article twenty-five of the public health law. Notwith- standing the foregoing, the health plan shall not require the insured to pay any such fee if such fee shall pose a hardship to the [enrollee] INSURED as determined by the plan. (2) THE HEALTH CARE PLAN MAY CHARGE THE INSURED'S HEALTH CARE PROVIDER A FEE OF UP TO FIFTY DOLLARS PER EXTERNAL APPEAL, OTHER THAN FOR AN EXTERNAL APPEAL REQUESTED PURSUANT TO PARAGRAPH TWO OR THREE OF SUBSECTION (D) OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS ARTICLE; PROVIDED THAT, IN THE EVENT THE EXTERNAL APPEAL AGENT OVERTURNS THE FINAL ADVERSE DETERMINATION OF THE PLAN, SUCH FEE SHALL BE REFUNDED TO THE INSURED'S HEALTH CARE PROVIDER. S 56. Paragraphs 4 and 5 of subsection (b) of section 4912 of the insurance law, as added by chapter 586 of the laws of 1998, are amended and a new paragraph 6 is added to read as follows: (4) establish a toll-free telephone service to receive information on a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant to this title. Such system shall be capable of accepting, recording or providing instruction to incoming telephone calls during other than normal business hours[, and]; (5) develop procedures to ensure that: (i) appropriate personnel are reasonably accessible not less than forty hours per week during normal business hours to discuss patient care and to allow response to telephone requests, and (ii) response to accepted or recorded messages shall be made not less than one business day after the date on which the call was received[.]; AND (6) BE ACCREDITED BY A NATIONALLY RECOGNIZED PRIVATE ACCREDITING ORGANIZATION. S 57. Paragraphs 1 and 3 of subsection (b) of section 4914 of the insurance law, paragraph 1 as added by chapter 586 of the laws of 1998 and paragraph 3 as amended by chapter 237 of the laws of 2009, are amended to read as follows: (1) The insured shall have [forty-five days] FOUR MONTHS to initiate an external appeal after the insured receives notice from the health care plan, or such plan's utilization review agent if applicable, of a final adverse determination or denial, or after both the plan and the [enrollee] INSURED have jointly agreed to waive any internal appeal, OR AFTER THE INSURED IS DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE ANY INTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19. WHERE APPLICABLE, THE INSURED'S HEALTH CARE PROVIDER SHALL HAVE FORTY-FIVE DAYS TO INITIATE AN EXTERNAL APPEAL AFTER THE INSURED OR THE INSURED'S HEALTH CARE PROVIDER, AS APPLICABLE, RECEIVES NOTICE FROM THE HEALTH CARE PLAN, OR SUCH PLAN'S UTILIZATION REVIEW AGENT IF APPLICABLE, OF A FINAL ADVERSE DETERMINATION OR DENIAL OR AFTER BOTH THE PLAN AND THE INSURED HAVE JOINTLY AGREED TO WAIVE ANY INTERNAL APPEAL. Such request shall be in writing in accord- ance with the instructions and in such form prescribed by subsection (e) of this section. The insured, and the insured's health care provider where applicable, shall have the opportunity to submit additional documentation with respect to such appeal to the external appeal agent within [such forty-five-day period] THE APPLICABLE TIME PERIOD ABOVE; provided however that when such documentation represents a material change from the documentation upon which the utilization review agent based its adverse determination or upon which the health plan based its
denial, the health plan shall have three business days to consider such documentation and amend or confirm such adverse determination. (3) Notwithstanding the provisions of paragraphs one and two of this subsection, if the insured's attending physician states that a delay in providing the health care service would pose an imminent or serious threat to the health of the insured, OR IF THE INSURED IS ENTITLED TO AN EXPEDITED EXTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19, the external appeal shall be completed within [three days] NO MORE THAN SEVENTY-TWO HOURS of the request therefor and the external appeal agent shall make every reason- able attempt to immediately notify the insured, the insured's health care provider where appropriate, and the health plan of its determi- nation by telephone or facsimile, followed immediately by written notification of such determination. S 58. Clause (a) of item (ii) of subparagraph (B) of paragraph 4 of subsection (b) of section 4914 of the insurance law, as amended by chap- ter 237 of the laws of 2009, is amended to read as follows: (a) that the patient costs of the proposed health service or procedure shall be covered by the health care plan either: when a majority of the panel of reviewers determines, based upon review of the applicable medical and scientific evidence and, in connection with rare diseases, the physician's certification required by subsection (g-7) of section four thousand nine hundred of this article and such other evidence as the insured, the insured's designee or the insured's attending physician may present (or upon confirmation that the recommended treatment is a clinical trial), the insured's medical record, and any other pertinent information, that the proposed health service or treatment (including a pharmaceutical product within the meaning of subparagraph (B) of para- graph two of subsection (e) of section four thousand nine hundred of this article) is likely to be more beneficial than any standard treat- ment or treatments for the insured's [life-threatening or disabling] condition or disease or, for rare diseases, that the requested health service or procedure is likely to benefit the insured in the treatment of the insured's rare disease and that such benefit to the insured outweighs the risks of such health service or procedure (or, in the case of a clinical trial, is likely to benefit the insured in the treatment of the insured's condition or disease); or when a reviewing panel is evenly divided as to a determination concerning coverage of the health service or procedure, or S 59. Section 4403 of the public health law is amended by adding a new subdivision 7 to read as follows: 7. A HEALTH MAINTENANCE ORGANIZATION THAT REQUIRES OR PROVIDES FOR DESIGNATION BY AN ENROLLEE OF A PARTICIPATING PRIMARY CARE PROVIDER SHALL PERMIT THE ENROLLEE TO DESIGNATE ANY PARTICIPATING PRIMARY CARE PROVIDER WHO IS AVAILABLE TO ACCEPT SUCH INDIVIDUAL, AND IN THE CASE OF A CHILD, SHALL PERMIT THE ENROLLEE TO DESIGNATE A PHYSICIAN (ALLOPATHIC OR OSTEOPATHIC) WHO SPECIALIZES IN PEDIATRICS AS THE CHILD'S PRIMARY CARE PROVIDER IF SUCH PROVIDER PARTICIPATES IN THE NETWORK OF THE HEALTH MAINTENANCE ORGANIZATION. S 60. Subdivisions 1 and 2 of section 4406-b of the public health law, as added by chapter 645 of the laws of 1994, are amended to read as follows: 1. The health maintenance organization shall not limit a female enrollee's direct access to primary and preventive obstetric and gyneco- logic services, INCLUDING ANNUAL EXAMINATIONS, CARE RESULTING FROM SUCH ANNUAL EXAMINATIONS, AND TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, from
a qualified provider of such services of her choice from within the plan [to less than two examinations annually for such services] or [to] FOR any care related to a pregnancy[. In addition, the health maintenance organization shall not limit direct access to primary and preventive obstetric and gynecologic services required as a result of such annual examinations or as a result of an acute gynecologic condition], provided that: (A) such qualified provider discusses such services and treatment plan with the enrollee's primary care practitioner in accordance with the requirements of the health maintenance organization; AND (B) SUCH QUALIFIED PROVIDER AGREES TO ADHERE TO THE HEALTH MAINTENANCE ORGANIZA- TION'S POLICIES AND PROCEDURES, INCLUDING ANY APPLICABLE PROCEDURES REGARDING REFERRALS AND OBTAINING PRIOR AUTHORIZATION FOR SERVICES OTHER THAN OBSTETRIC AND GYNECOLOGIC SERVICES RENDERED BY SUCH QUALIFIED PROVIDER, AND AGREES TO PROVIDE SERVICES PURSUANT TO A TREATMENT PLAN (IF ANY) APPROVED BY THE HEALTH MAINTENANCE ORGANIZATION. 2. A HEALTH MAINTENANCE ORGANIZATION SHALL TREAT THE PROVISION OF OBSTETRIC AND GYNECOLOGIC CARE, AND THE ORDERING OF RELATED OBSTETRIC AND GYNECOLOGIC ITEMS AND SERVICES, PURSUANT TO THE DIRECT ACCESS DESCRIBED IN SUBDIVISION ONE OF THIS SECTION BY A PARTICIPATING QUALI- FIED PROVIDER OF SUCH SERVICES, AS THE AUTHORIZATION OF THE PRIMARY CARE PROVIDER. 3. It shall be the duty of the administrative officer or other person in charge of each health maintenance organization to advise each female enrollee, in writing, of the provisions of this section. S 61. Subdivision 3 of section 4900 of the public health law, as added by chapter 705 of the laws of 1996, is amended to read as follows: 3. "Emergency condition" means a medical or behavioral condition, [the onset of which is sudden,] that manifests itself by ACUTE symptoms of sufficient severity, including severe pain, SUCH that a prudent layper- son, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impair- ment to such person's bodily functions; (c) serious dysfunction of any bodily organ or part of such person; [or] (d) serious disfigurement of such person; OR (E) A CONDITION DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE SOCIAL SECURITY ACT. S 62. Subdivision 7-g of section 4900 of the public health law, as added by chapter 237 of the laws of 2009, is amended to read as follows: 7-g. "Rare disease" means a [life threatening or disabling] condition or disease that (1)(A) is currently or has been subject to a research study by the National Institutes of Health Rare Diseases Clinical Research Network or (B) affects fewer than two hundred thousand United States residents per year, and (2) for which there does not exist a standard health service or procedure covered by the health care plan that is more clinically beneficial than the requested health service or treatment. A physician, other than the enrollee's treating physician, shall certify in writing that the condition is a rare disease as defined in this subsection. The certifying physician shall be a licensed, board- certified or board-eligible physician who specializes in the area of practice appropriate to treat the enrollee's rare disease. The certif- ication shall provide either: (1) that the insured's rare disease is currently or has been subject to a research study by the National Insti- tutes of Health Rare Diseases Clinical Research Network; or (2) that the insured's rare disease affects fewer than two hundred thousand United
States residents per year. The certification shall rely on medical and scientific evidence to support the requested health service or proce- dure, if such evidence exists, and shall include a statement that, based on the physician's credible experience, there is no standard treatment that is likely to be more clinically beneficial to the enrollee than the requested health service or procedure and the requested health service or procedure is likely to benefit the enrollee in the treatment of the enrollee's rare disease and that such benefit to the enrollee outweighs the risks of such health service or procedure. The certifying physician shall disclose any material financial or professional relationship with the provider of the requested health service or procedure as part of the application for external appeal of denial of a rare disease treatment. If the provision of the requested health service or procedure at a health care facility requires prior approval of an institutional review board, an enrollee or enrollee's designee shall also submit such approval as part of the external appeal application. S 63. Subparagraphs (i) and (ii) of paragraph (a) of subdivision 2 of section 4910 of the public health law, as added by chapter 586 of the laws of 1998, are amended to read as follows: (i) the enrollee has had coverage of a health care service, which would otherwise be a covered benefit under a subscriber contract or governmental health benefit program, denied on appeal, in whole or in part, pursuant to title one of this article on the grounds that such health care service [is not medically necessary] DOES NOT MEET THE HEALTH CARE PLAN'S REQUIREMENTS FOR MEDICAL NECESSITY, APPROPRIATENESS, HEALTH CARE SETTING, LEVEL OF CARE, OR EFFECTIVENESS OF A COVERED BENE- FIT, and (ii) the health care plan has rendered a final adverse determination with respect to such health care service or both the plan and the enrol- lee have jointly agreed to waive any internal appeal, OR THE ENROLLEE IS DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE ANY INTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19; or S 64. Subparagraphs (i), (ii) and (iii) of paragraph (b) of subdivi- sion 2 of section 4910 of the public health law, subparagraph (i) as added by chapter 586 of the laws of 1998, and subparagraphs (ii) and (iii) as amended by chapter 237 of the laws of 2009, are amended to read as follows: (i) the enrollee has had coverage of a health care service denied on the basis that such service is experimental or investigational, and such denial has been upheld on appeal under title one of this article, or both the plan and the enrollee have jointly agreed to waive any internal appeal, OR THE ENROLLEE IS DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE ANY INTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE FEDERAL PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19, and (ii) the enrollee's attending physician has certified that the enrol- lee has a [life-threatening or disabling] condition or disease (a) for which standard health services or procedures have been ineffective or would be medically inappropriate, or (b) for which there does not exist a more beneficial standard health service or procedure covered by the health care plan, or (c) for which there exists a clinical trial or rare disease treatment, and (iii) the enrollee's attending physician, who must be a licensed, board-certified or board-eligible physician qualified to practice in the area of practice appropriate to treat the enrollee's [life threatening or disabling] condition or disease, must have recommended either (a) a
health service or procedure (including a pharmaceutical product within the meaning of subparagraph (B) of paragraph (b) of subdivision five of section forty-nine hundred of this article) that, based on two documents from the available medical and scientific evidence, is likely to be more beneficial to the enrollee than any covered standard health service or procedure or, in the case of a rare disease, based on the physician's certification required by subdivision seven-g of section forty-nine hundred of this article and such other evidence as the enrollee, the enrollee's designee or the enrollee's attending physician may present, that the requested health service or procedure is likely to benefit the enrollee in the treatment of the enrollee's rare disease and that such benefit to the enrollee outweighs the risks of such health service or procedure; or (b) a clinical trial for which the enrollee is eligible. Any physician certification provided under this section shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation, and S 65. Subdivision 3 of section 4910 of the public health law, as added by chapter 586 of the laws of 1998, is amended to read as follows: 3. (A) The health care plan may charge the enrollee a fee of up to [fifty] TWENTY-FIVE dollars per external appeal WITH AN ANNUAL LIMIT ON FILING FEES FOR AN ENROLLEE NOT TO EXCEED SEVENTY-FIVE DOLLARS WITHIN A SINGLE PLAN YEAR; provided that, in the event the external appeal agent overturns the final adverse determination of the plan, such fee shall be refunded to the enrollee. Notwithstanding the foregoing, the health plan shall not require the enrollee to pay any such fee if the enrollee is a recipient of medical assistance or is covered by a policy pursuant to title one-A of article twenty-five of this chapter. Notwithstanding the foregoing, the health plan shall not require the enrollee to pay any such fee if such fee shall pose a hardship to the enrollee as determined by the plan. (B) THE HEALTH CARE PLAN MAY CHARGE THE ENROLLEE'S HEALTH CARE PROVID- ER A FEE OF UP TO FIFTY DOLLARS PER EXTERNAL APPEAL, OTHER THAN FOR AN EXTERNAL APPEAL REQUESTED PURSUANT TO PARAGRAPH (B) OR (C) OF SUBDIVI- SION FOUR OF SECTION FORTY-NINE HUNDRED FOURTEEN OF THIS ARTICLE; PROVIDED THAT, IN THE EVENT THE EXTERNAL APPEAL AGENT OVERTURNS THE FINAL ADVERSE DETERMINATION OF THE PLAN, SUCH FEE SHALL BE REFUNDED TO THE ENROLLEE'S HEALTH CARE PROVIDER. S 66. Paragraphs (d) and (e) of subdivision 2 of section 4912 of the public health law, as added by chapter 586 of the laws of 1998, are amended and a new paragraph (f) is added to read as follows: (d) establish a toll-free telephone service to receive information on a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant to this title. Such system shall be capable of accepting, recording or providing instruction to incoming telephone calls during other than normal business hours[, and]; (e) develop procedures to ensure that: (i) appropriate personnel are reasonably accessible not less than forty hours per week during normal business hours to discuss patient care and to allow response to telephone requests, and (ii) response to accepted or recorded messages shall be made not less than one business day after the date on which the call was received[.]; AND (F) BE ACCREDITED BY A NATIONALLY RECOGNIZED PRIVATE ACCREDITING ORGANIZATION. S 67. Paragraphs (a) and (c) of subdivision 2 of section 4914 of the public health law, paragraph (a) as added by chapter 586 of the laws of
1998 and paragraph (c) as amended by chapter 237 of the laws of 2009, are amended to read as follows: (a) The enrollee shall have [forty-five days] FOUR MONTHS to initiate an external appeal after the enrollee receives notice from the health care plan, or such plan's utilization review agent if applicable, of a final adverse determination or denial or after both the plan and the enrollee have jointly agreed to waive any internal appeal, OR AFTER THE ENROLLEE IS DEEMED TO HAVE EXHAUSTED OR IS NOT REQUIRED TO COMPLETE ANY INTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19. WHERE APPLICABLE, THE ENROLLEE'S HEALTH CARE PROVIDER SHALL HAVE FORTY-FIVE DAYS TO INITIATE AN EXTERNAL APPEAL AFTER THE ENROLLEE OR THE ENROLLEE'S HEALTH CARE PROVIDER, AS APPLICABLE, RECEIVES NOTICE FROM THE HEALTH CARE PLAN, OR SUCH PLAN'S UTILIZATION REVIEW AGENT IF APPLICABLE, OF A FINAL ADVERSE DETERMINATION OR DENIAL OR AFTER BOTH THE PLAN AND THE ENROLLEE HAVE JOINTLY AGREED TO WAIVE ANY INTERNAL APPEAL. Such request shall be in writing in accordance with the instructions and in such form prescribed by subdivision five of this section. The enrollee, and the enrollee's health care provider where applicable, shall have the opportunity to submit additional documenta- tion with respect to such appeal to the external appeal agent within [such forty-five-day period] THE APPLICABLE TIME PERIOD ABOVE; provided however that when such documentation represents a material change from the documentation upon which the utilization review agent based its adverse determination or upon which the health plan based its denial, the health plan shall have three business days to consider such documen- tation and amend or confirm such adverse determination. (c) Notwithstanding the provisions of paragraphs (a) and (b) of this subdivision, if the enrollee's attending physician states that a delay in providing the health care service would pose an imminent or serious threat to the health of the enrollee, OR IF THE ENROLLEE IS ENTITLED TO AN EXPEDITED EXTERNAL APPEAL PURSUANT TO SECTION 2719 OF THE FEDERAL PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-19, the external appeal shall be completed within [three days] NO MORE THAN SEVENTY-TWO HOURS of the request therefor and the external appeal agent shall make every reasonable attempt to immediately notify the enrollee, the enrollee's health care provider where appropriate, and the health plan of its determination by telephone or facsimile, followed immediately by written notification of such determination. S 68. Item 1 of clause (ii) of subparagraph (B) of paragraph (d) of subdivision 2 of section 4914 of the public health law, as amended by chapter 237 of the laws of 2009, is amended to read as follows: (1) that the patient costs of the proposed health service or procedure shall be covered by the health care plan either: when a majority of the panel of reviewers determines, based upon review of the applicable medical and scientific evidence and, in connection with rare diseases, the physician's certification required by subdivision seven-g of section forty-nine hundred of this article and such other evidence as the enrol- lee, the enrollee's designee or the enrollee's attending physician may present (or upon confirmation that the recommended treatment is a clin- ical trial), the enrollee's medical record, and any other pertinent information, that the proposed health service or treatment (including a pharmaceutical product within the meaning of subparagraph (B) of para- graph (b) of subdivision five of section forty-nine hundred of this article) is likely to be more beneficial than any standard treatment or treatments for the enrollee's [life-threatening or disabling] condition or disease or, for rare diseases, that the requested health service or
procedure is likely to benefit the enrollee in the treatment of the enrollee's rare disease and that such benefit to the enrollee outweighs the risks of such health service or procedure (or, in the case of a clinical trial, is likely to benefit the enrollee in the treatment of the enrollee's condition or disease); or when a reviewing panel is even- ly divided as to a determination concerning coverage of the health service or procedure, or S 69. If any provision of this act or the application thereof shall be held to be invalid, such invalidity shall not affect other provisions of this act which can be given effect without the invalid provision; and to that end, the provisions of this act are severable. S 70. This act shall take effect immediately: 1. provided, that for policies renewed on or after such date but before September 23, 2011, this act shall take effect upon the renewal date; 2. provided, however, that sections eight, nine, ten, fourteen, fifteen, sixteen, seventeen, eighteen, twenty-three, twenty-six, twen- ty-seven, twenty-eight, twenty-nine, thirty, forty, forty-one, forty-two and forty-three of this act shall, with respect to blanket policies of hospital, medical, surgical or prescription drug expense insurance covering students pursuant to subparagraph (C) of paragraph 3 of subsection (a) of section 4237 of the insurance law, take effect January 1, 2012 and apply to policies issued or renewed on and after such date; and 3. provided, further, that sections fifty-two, fifty-three, fifty- four, fifty-five, fifty-six, fifty-seven, fifty-eight, sixty-two, sixty-three, sixty-four, sixty-five, sixty-six, sixty-seven and sixty- eight of this act shall take effect on the later of July 1, 2011, or the date the external appeal requirements of section 2719 of the Public Health Service Act, 42 U.S.C. S 300gg-19 are determined to be effective by the Secretary of Health and Human Services and apply to a final adverse determination issued on and after such date.

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