Section 3221. Group or blanket accident and health insurance policies; standard provisions

(a) No policy of  group  or  blanket  accident  and  health  insurance shall, except as provided in subsection (d) hereof, be
  delivered or issued for delivery in this state  unless  it  contains  in
  substance the following provisions or provisions which in the opinion of
  the   superintendent   are   more  favorable  to  the  holders  of  such
  certificates or not less favorable to the holders of  such  certificates
  and   more  favorable  to  policyholders,  provided  however,  that  the
  provisions set forth in paragraphs six and thirteen of  this  subsection
  shall  not  be  applicable  to  any  such  policy  which  is issued to a
  policyholder in accordance with subparagraph (E)  of  paragraph  one  of
  subsection  (c) of section four thousand two hundred thirty-five of this
  chapter:
    (1) (A) No statement made  by  the  person  insured  shall  avoid  the
  insurance  or  reduce  benefits thereunder unless contained in a written
  instrument signed by the person insured.
    (B) All statements contained in any such written instrument  shall  be
  deemed representations and not warranties.
    (2)  That  no agent has authority to change the policy or waive any of
  its provisions and that no change in the policy shall  be  valid  unless
  approved  by  an  officer of the insurer and evidenced by endorsement on
  the policy, or by amendment to the policy signed by the policyholder and
  the insurer.
    (3) That all new employees or new members in the classes eligible  for
  insurance must be added to such class for which they are eligible.
    (4)  That  all  premiums due under the policy shall be remitted by the
  employer or employers of the persons insured or by some other designated
  person acting on behalf of the association  or  group  insured,  to  the
  insurer  on or before the due date thereof, with such period of grace as
  may be specified therein.
    (5) The conditions under which the insurer may decline  to  renew  the
  policy.
    (6)  That  the insurer shall issue either to the employer or person in
  whose name such policy is issued, for delivery to  each  member  of  the
  insured  group,  a certificate setting forth in summary form a statement
  of the essential features of the insurance coverage and in substance the
  following provisions of this subsection.
    (7) The ages,  to  which  the  insurance  provided  therein  shall  be
  limited;  and  the ages, for which additional restrictions are placed on
  benefits, and the additional restrictions placed on the benefits at such
  ages.
    (8) That written notice of claim must be given to the  insurer  within
  twenty  days after the occurrence or commencement of any loss covered by
  the policy. Failure to give notice within such time shall not invalidate
  or reduce any claim if it shall be shown not  to  have  been  reasonably
  possible  to  give  such notice and that notice was given as soon as was
  reasonably possible.
    * (9) That in the case of claim  for  loss  of  time  for  disability,
  written  proof  of  such  loss  must  be furnished to the insurer within
  thirty days after the commencement of the period for which  the  insurer
  is liable, and that subsequent written proofs of the continuance of such
  disability  must  be  furnished  to the insurer at such intervals as the
  insurer may reasonably require, and that in the case of  claim  for  any
  other  loss, written proof of such loss must be furnished to the insurer
  within ninety days after the date of such loss. Failure to furnish  such
  proof  within  such  time shall not invalidate or reduce any claim if it
  shall be shown not to have been  reasonably  possible  to  furnish  such

  proof  within  such  time,  provided such proof was furnished as soon as
  reasonably possible.
    * NB Effective until January 1, 2011
    * (9)  That  in  the  case  of  claim for loss of time for disability,
  written proof of such loss must  be  furnished  to  the  insurer  within
  thirty  days  after the commencement of the period for which the insurer
  is liable, and that subsequent written proofs of the continuance of such
  disability must be furnished to the insurer at  such  intervals  as  the
  insurer  may  reasonably  require, and that in the case of claim for any
  other loss, written proof of such loss must be furnished to the  insurer
  within  one  hundred twenty days after the date of such loss. Failure to
  furnish such proof within such time shall not invalidate or  reduce  any
  claim  if  it  shall  be  shown  not to have been reasonably possible to
  furnish such proof within such time, provided such proof  was  furnished
  as soon as reasonably possible.
    * NB Effective January 1, 2011
    (10)  That  the  insurer will furnish to the person making claim or to
  the policyholder for delivery to such person such forms as  are  usually
  furnished  by  it  for  filing  proof  of  loss.  If  such forms are not
  furnished before the  expiration  of  fifteen  days  after  the  insurer
  receives  notice  of  any claim under the policy, the person making such
  claim shall be deemed to have complied  with  the  requirements  of  the
  policy  as to proof of loss upon submitting within the time fixed in the
  policy for filing proof of loss, written proof covering the  occurrence,
  character and extent of the loss for which claim is made.
    (11)  That the insurer shall have the right and opportunity to examine
  the person of the individual for whom claim is made when and so often as
  it may reasonably require during the pendency of claim under the  policy
  and  also  the right and opportunity to make an autopsy in case of death
  where it is not prohibited by law.
    (12) That benefits payable under the policy other  than  benefits  for
  loss  of  time will be payable not more than sixty days after receipt of
  proof, and that, subject to due  proof  of  loss  all  accrued  benefits
  payable  under  the  policy  for  loss  of  time  will  be paid not less
  frequently than monthly during the continuance of the period  for  which
  the  insurer  is  liable,  and  that any balance remaining unpaid at the
  termination of such period will be paid immediately upon receipt of such
  proof.
    (13) That indemnity for loss of life of  the  insured  is  payable  in
  accordance  with  subsection  (e)  of  section four thousand two hundred
  thirty-five of this chapter; and  that  all  other  indemnities  of  the
  policy  are  payable to the insured, except as may be otherwise provided
  in accordance with  such  subsection;  and  that  if  a  beneficiary  is
  designated,  the  consent  of  the beneficiary shall not be requisite to
  change of beneficiary,  or  to  any  other  changes  in  the  policy  or
  certificate, except as may be specifically provided by the policy.
    (14) That no action at law or in equity shall be brought to recover on
  the policy prior to the expiration of sixty days after proof of loss has
  been filed in accordance with the requirements of the policy and that no
  such action shall be brought after the expiration of two years following
  the time such proof of loss is required by the policy.
    (15)  Any policy and certificate, other than one issued in fulfillment
  of the continuing care responsibilities of an operator of  a  continuing
  care  retirement  community  in accordance with article forty-six of the
  public health law, made available because of residence in  a  particular
  facility,  housing development, or community shall contain the following
  notice in twelve point type in bold face on the first page:

    "NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF
  A CONTINUING CARE RETIREMENT CONTRACT.  AVAILABILITY  OF  THIS  COVERAGE
  WILL  NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT
  COMMUNITY."
    (b)  No  such policy shall be delivered or issued for delivery in this
  state unless a schedule of the premium rates  pertaining  to  such  form
  shall have been filed with the superintendent.
    (c)  Any  portion of any such policy, which purports, by reason of the
  circumstances under which a loss is incurred,  to  reduce  any  benefits
  promised  thereunder  to  an amount less than that provided for the same
  loss occurring under ordinary circumstances, shall be printed,  in  such
  policy  and in each certificate issued thereunder, in bold face type and
  with greater prominence than any other  portion  of  the  text  of  such
  policy  or  certificate; and all other exceptions of the policy shall be
  printed in the policy and in the certificate, with the  same  prominence
  as  the  benefits  to  which they apply. If any such policy contains any
  provision which affects the liability of the  insurer,  on  the  grounds
  stated  in subparagraph (J) or (K) of paragraph two of subsection (d) of
  section three thousand two hundred sixteen of this  article,  then  such
  provision  shall  be contained in the policy and certificate in the form
  set forth in such section.
    (d) (1) The superintendent may approve any form of certificate  to  be
  issued  under  a blanket accident and health insurance policy as defined
  in section four thousand two hundred thirty-seven of this chapter, which
  omits or modifies any of the provisions  hereinbefore  required,  if  he
  deems  such  omission or modification suitable for the character of such
  insurance and not unjust to the persons insured thereunder.
    (2) The superintendent may approve any form of group insurance  policy
  providing  disability  benefits to be issued pursuant to article nine of
  the workers' compensation  law  which  omits  or  modifies  any  of  the
  provisions  hereinbefore  required,  if such omission or modification is
  not inconsistent with the provisions of such article nine and  he  deems
  such  omission  or  modification  suitable  for  the  character  of such
  insurance and not unjust to the persons insured thereunder.
    (3) The superintendent may also approve any form  of  group  insurance
  policy   to  be  issued  to  a  social  services  district  pursuant  to
  subdivision two of section three hundred  sixty-seven-a  of  the  social
  services law, which omits or modifies any of the provisions hereinbefore
  required,  if  he  deems  such omission or modification suitable for the
  character of such insurance.
    (e)  (1)  A  group  policy  providing  hospital  or  surgical  expense
  insurance  for  other  than  specific  diseases  or accident only, shall
  provide that if the insurance on an employee or member insured under the
  group policy ceases because of  termination  of  (I)  employment  or  of
  membership  in  the  class  or  classes  eligible for coverage under the
  policy or (II)  the  policy,  for  any  reason  whatsoever,  unless  the
  policyholder  has  replaced the group policy with similar and continuous
  coverage for the  same  group  whether  insured  or  self-insured,  such
  employee  or  member  who has been insured under the group policy for at
  least three months shall be entitled  to  have  issued  to  him  by  the
  insurer  without  evidence  of insurability upon application made to the
  insurer within forty-five days after such termination,  and  payment  of
  the  quarterly,  or,  at  the  option  of the employee or member, a less
  frequent premium applicable to the class of risk  to  which  the  person
  belongs,  the  age of such person, and the form and amount of insurance,
  an individual policy of insurance. The insurer may, at its option  elect
  to  provide  the  insurance  coverage  under  a  group insurance policy,
  delivered in this  state,  in  lieu  of  the  issuance  of  a  converted

  individual policy of insurance. Such individual policy, or group policy,
  as the case may be is hereafter referred to as the converted policy. The
  benefits  provided under the converted policy shall be those required by
  subsection  (f), (g), (h) or (i) hereof, whichever is applicable and, in
  the event of termination of the converted  group  policy  of  insurance,
  each  insured thereunder shall have a right of conversion to a converted
  individual policy of insurance.
    (2) The insurer shall not be required  to  issue  a  converted  policy
  covering  any  person  if such person is covered for similar benefits by
  another hospital or surgical or  medical  expense  insurance  policy  or
  hospital  or  medical service subscriber contract or medical practice or
  other prepayment plan or by any other plan or program or such person  is
  eligible  for  similar  benefits, whether or not covered therefor, under
  any arrangement of coverage for individuals in a group, other than under
  the converted policy, whether  on  an  insured  or  uninsured  basis  or
  similar  benefits  are provided for or available to such person pursuant
  to any statute; and the benefits provided or available under any of such
  sources which together with the benefits provided  under  the  converted
  policy   would  result  in  overinsurance  or  duplication  of  benefits
  according to standards on file with the superintendent.
    (3) The converted policy shall, at  the  option  of  the  employee  or
  member,  provide  identical coverage for the dependents of such employee
  or member who were covered under the group  policy.  Provided,  however,
  that  if the employee or member chooses the option of dependent coverage
  then dependents acquired after the permitted time to convert  stated  in
  paragraph  one of this subsection shall be added to the converted family
  policy in accordance with the provisions of subsection  (c)  of  section
  thirty-two   hundred   sixteen  of  this  article  and  any  regulations
  promulgated or guidelines issued by the  superintendent.  The  converted
  policy  need  not  provide benefits in excess of those provided for such
  persons under the group policy from which conversion  is  made  and  may
  contain  any  exclusion  or  benefit  limitation  contained in the group
  policy or customarily used in individual policies. The effective date of
  the individual's coverage under the converted policy shall be  the  date
  of  the termination of the individual's insurance under the group policy
  as to those persons covered under the group policy.
    (4) The converted policy shall not exclude  a  pre-existing  condition
  not  excluded  by  the  group  policy  but may provide that any benefits
  payable thereunder may be reduced by the amount  of  any  such  benefits
  payable under the group policy after the termination of the individual's
  insurance  thereunder,  and  during  the first year of such individual's
  coverage under the converted  policy  the  benefits  payable  under  the
  policy may be reduced so that they are not in excess of those that would
  have  been payable had the individual's insurance under the group policy
  remained in effect. The converted policy may provide for termination  of
  coverage  thereunder  on  any  person  when he is or could be covered by
  Medicare (subchapter XVIII of the federal Social Security Act, 42 U.S.C.
  §§ 1395 et seq) by reason of age.
    (5) If delivery of an  individual  converted  policy  is  to  be  made
  outside  this  state,  it may be on such form as the insurer may then be
  offering for such conversion in the jurisdiction where such delivery  is
  to be made.
    (6)  (A)  A  converted  policy  may  include  a  provision whereby the
  insurer, during the first two years of an  individual's  coverage  under
  the  policy,  may request information in advance of any premium due date
  of such policy of any person covered thereunder  as  to  whether  he  is
  covered  for similar benefits by another hospital or surgical or medical
  expense insurance policy  or  hospital  or  medical  service  subscriber

  contract  or  medical  practice or other prepayment plan or by any other
  plan or program or similar benefits are provided for, or  available  to,
  such person pursuant to any statute.
    (B)  If  any  such person is so covered or such statutory benefits are
  provided or available, and such person fails to furnish the insurer  the
  details  of such coverage within thirty-one days after such request, the
  benefits payable under the converted policy with respect to such  person
  may  be  based  on the hospital or surgical or medical expenses actually
  incurred after excluding  expenses  to  the  extent  of  the  amount  of
  benefits provided or available therefor from any of the sources referred
  to in subparagraph (A) hereof.
    (7) The conversion provision shall also be available upon the death of
  the  employee or member, to the surviving spouse with respect to such of
  the spouse and children as are then covered by  the  group  policy,  and
  shall  be  available  to a child solely with respect to himself upon his
  attaining the limiting age of coverage  under  the  group  policy  while
  covered  as  a dependent thereunder. It shall also be available upon the
  divorce or annulment of the marriage of the employee or member,  to  the
  former spouse of such employee or member.
    (8)  (A) Each certificate holder shall be given written notice of such
  conversion privilege and its duration  within  fifteen  days  before  or
  after  the  date of termination of group coverage, provided that if such
  notice be given more than fifteen days but less than ninety  days  after
  the  date  of  termination  of  group coverage, the time allowed for the
  exercise  of  such  privilege  of  conversion  shall  be  extended   for
  forty-five  days  after the giving of such notice. If such notice be not
  given within  ninety  days  after  the  date  of  termination  of  group
  coverage, the time allowed for the exercise of such conversion privilege
  shall expire at the end of such ninety days.
    (B) Written notice by the policyholder given to the certificate holder
  or  mailed  to  the  certificate holder's last known address, or written
  notice by the insurer be sent by first class  mail  to  the  certificate
  holder at the last address furnished to the insurer by the policyholder,
  shall  be  deemed full compliance with the provisions of this subsection
  for the giving of notice.
    (C) A group contract issued by an insurer may contain a  provision  to
  the  effect  that  notice  of such conversion privilege and its duration
  shall be given by the  policyholder  to  each  certificate  holder  upon
  termination of his group coverage.
    (9)  This  subsection  shall  not  apply to a group policy issued to a
  policyholder whose principal activities are located outside  this  state
  by  any  life insurance company organized and operated without profit to
  any private shareholder or individual, and operated exclusively for  the
  purpose  of  aiding and strengthening charitable, religious, missionary,
  education or philanthropic institutions, by issuing insurance  contracts
  only  to or for the benefit of such institutions, to individuals engaged
  in the services of such institutions and to  members  of  the  immediate
  families of such individuals.
    (10)  (A)  This  subsection shall not apply to a group policy insuring
  persons employed in an establishment  located  outside  this  state  and
  their  dependents  issued  by  a  life  insurance company which has been
  organized  for  the  purpose  of  establishing  a  non-profit  voluntary
  employee  beneficiary association to provide life, sickness, accident or
  other benefits to eligible employees or their beneficiaries, is operated
  exclusively for said purposes and without profit, direct or indirect, to
  any private shareholder or individual, and is duly  exempt  from  income
  taxation, pursuant to the federal Internal Revenue Code.

    (B)  Notwithstanding  the  provisions  of subparagraph (A) hereof, any
  resident of this state and his dependents who are insured under a  group
  policy  providing  hospital or surgical expense insurance for other than
  specific diseases or accident only which is issued by a  life  insurance
  company organized as aforementioned, shall be entitled to the conversion
  privileges specified in this subsection.
    (11)  In  addition  to the right of conversion herein, the employee or
  member insured under the policy shall at his option, as  an  alternative
  to  conversion,  be  entitled  to  have his coverage continued under the
  group policy in accordance with the conditions and limitations contained
  in subsection (m) of this section, and have issued at  the  end  of  the
  period  of  continuation  an individual conversion policy subject to the
  terms of this subsection. The effective date for the  conversion  policy
  shall  be the day following the termination of insurance under the group
  policy, or if there is a continuation of coverage, on the day  following
  the  end  of  the period of continuation. Notwithstanding the foregoing,
  the superintendent may require conversion or continuation  of  insurance
  under  conditions  as  set  forth  in  a regulation for insureds under a
  policy issued in accordance with subparagraph (E) of  paragraph  one  of
  subsection  (c) of section four thousand two hundred thirty-five of this
  chapter.
    (f) Any employee or  member  who  upon  becoming  entitled  to  obtain
  coverage  under  a converted policy has attained age sixty, and has been
  insured for at least  two  years  under  the  group  policy  immediately
  preceding  the  date  the  employee or member first became entitled to a
  converted policy shall have the privilege of obtaining such policy for a
  premium computed at a rate which in any policy year shall not exceed one
  hundred  twenty  percent  of  a  net  level  premium  approved  by   the
  superintendent  and  determined,  according  to  the attained age of the
  insured at the time of conversion and the plan of reimbursement elected,
  on the basis of current experience of licensed insurers  providing  such
  coverage  and  of  reasonable assumptions as to morbidity, mortality and
  interest. Such net level premium  may  be  changed  in  accordance  with
  experience  and  with the approval of the superintendent at intervals of
  not more frequently  than  five  years.  Notwithstanding  the  foregoing
  provisions  of  this subsection, nothing herein shall be construed so as
  to avoid the requirements of open enrollment and community rating as set
  forth elsewhere in this chapter.
    (g) The conversion privilege shall,  if  the  group  insurance  policy
  insures  the  employee  or member for basic hospital or surgical expense
  insurance, or if the group insurance  policy  insures  the  employee  or
  member for comprehensive medical expense insurance, entitle the employee
  or  member to obtain coverage under a converted policy providing, at his
  option, coverage under any one of the  following  plans  on  an  expense
  incurred basis:
    (1) Plan I.
    (A)  hospital  room  and  board expense benefits of one hundred thirty
  dollars per day for a maximum duration of twenty-one days,
    (B) miscellaneous hospital expense benefits of a maximum amount of one
  thousand three hundred dollars, and
    (C) surgical operation expense benefits according to  a  one  thousand
  four hundred dollar maximum benefit schedule, or
    (2) Plan II.
    (A)  hospital  room  and  board expense benefits of two hundred thirty
  dollars per day for a maximum duration of thirty days,
    (B) miscellaneous hospital expense benefits of a maximum amount of two
  thousand three hundred dollars, and

    (C) surgical operation expense benefits according to  a  two  thousand
  four hundred dollar maximum benefit schedule, or
    (3) Plan III.
    (A)  hospital  room and board expense benefits of three hundred thirty
  dollars a day for a maximum duration of seventy days,
    (B) miscellaneous hospital benefits  of  a  maximum  amount  of  three
  thousand three hundred dollars, and
    (C)  surgical operation expense benefits according to a three thousand
  five hundred dollar maximum benefit schedule.
    (h) The conversion privilege shall,  if  the  group  insurance  policy
  insures  the  employee or member for major medical expense insurance, or
  if the group  insurance  policy  insures  the  employee  or  member  for
  comprehensive  medical expense insurance, entitle the employee or member
  to obtain coverage under a  converted  policy  providing  major  medical
  coverage  under  one of the following plans or one at least as favorable
  to the covered persons:
    (1) A maximum conforming to subparagraph (A) or (B) hereof:
    (A) A maximum payment of two hundred thousand dollars for all  covered
  medical  expenses combined during the covered person's lifetime, with an
  annual restoration on each January first while coverage is in force,  up
  to  five  thousand  dollars  of  the  amount counted against the maximum
  benefit and not previously restored.
    (B) A maximum  payment  of  two  hundred  thousand  dollars  for  each
  unrelated injury or sickness.
    (2)  Payment  of  benefits  up  to  eighty  percent of covered medical
  expenses which are in excess of the deductible,  except  that  when  the
  combined deductible and other out-of-pocket covered medical expenses not
  reimbursed  by any other hospital, surgical or medical insurance policy,
  or hospital or medical subscriber contract, or  other  prepayment  plan,
  exceed  two  thousand  dollars, then payment of benefits shall be at one
  hundred percent of covered medical expenses.
    (3) (A) A deductible which is the greater of one thousand dollars  and
  the benefits deductible.
    (B) The term "benefits deductible", as used herein, means the value of
  any  benefits  provided  on an expense incurred basis which are provided
  with  respect  to  covered  medical  expenses  by  any  other  hospital,
  surgical,  or  medical  insurance  policy or hospital or medical service
  subscriber contract or medical practice or other prepayment plan, or any
  other plan or program whether on an insured or uninsured  basis,  or  in
  accordance  with  the  requirements  of  any statute and, if pursuant to
  subsection (i) hereof, the converted policy provides both basic hospital
  or surgical coverage and major medical coverage, the value of such basic
  benefits.
    (C) The insurer may require that the deductible be satisfied during  a
  period of not less than three months.
    (4)  (A)  The  benefit  period  shall  be  each calendar year when the
  maximum payment is determined  by  subparagraph  (A)  of  paragraph  one
  hereof  or  twenty-four months when the maximum payment is determined by
  subparagraph (B) of paragraph one hereof.
    (B) For the purpose of determining  the  benefits  payable,  the  term
  "covered  medical  expenses",  as  used  above, is defined as the actual
  expense incurred, provided however, for hospital room and board  charges
  an  insurer  may  limit the maximum major medical benefit payable to the
  lesser of the hospital's most common semi-private room and board  charge
  or  three  hundred  thirty  dollars per day and, in the case of surgical
  charges, an insurer may limit the maximum major medical benefit  payable
  to  the  lesser of seventy-five percent of the prevailing reasonable and

  customary charges or the benefit payable pursuant  to  a  four  thousand
  five hundred dollar maximum benefit schedule.
    (i)  The  conversion  privilege  shall,  if the group insurance policy
  insures the employee or member for basic hospital  or  surgical  expense
  insurance as well as major medical expense insurance, make available the
  plans  of  benefits  set forth in subsections (g) and (h) hereof. At the
  option of the insurer, such plans of benefits may be provided under  one
  policy.
    (j)  No policy of group or blanket accident and health insurance shall
  be issued as excess coverage for volunteer firemen over  and  above  the
  coverage  provided  for  pursuant to the volunteer firemen's benefit law
  unless such excess policy provides for each of the  types  of  coverages
  set  forth  in  subdivision  one of section five of such law. Any excess
  policy which does not contain such provisions shall be construed  as  if
  such coverages were embodied therein.
    (k)  (1)  (A)  Every  group policy delivered or issued for delivery in
  this state which provides coverage for in-patient  hospital  care  shall
  provide  coverage  for home care to residents in this state, except that
  this provision shall not apply to a policy which 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. Such home care coverage shall be included at the inception of
  all new policies and, with respect to all other policies, added  at  any
  anniversary date of the policy subject to evidence of insurability.
    (B)  Such  coverage may be subject to an annual deductible of not more
  than fifty dollars for each person covered under the policy and  may  be
  subject  to  a  coinsurance provision which provides for coverage of not
  less than seventy-five  percent  of  the  reasonable  charges  for  such
  services.
    (C)  Home care means the care and treatment of a covered person who is
  under the care of a physician but only if hospitalization or confinement
  in a nursing facility as defined in  subchapter  XVIII  of  the  federal
  Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been
  required  if  home care was not provided, and the plan covering the home
  health service is established and approved in writing by such physician.
    (D) Home care shall be  provided  by  an  agency  possessing  a  valid
  certificate of approval or license issued pursuant to article thirty-six
  of  the  public  health  law  and  shall  consist  of one or more of the
  following:
    (i) Part-time or intermittent  home  nursing  care  by  or  under  the
  supervision of a registered professional nurse (R.N.).
    (ii) Part-time or intermittent home health aide services which consist
  primarily of caring for the patient.
    (iii) Physical, occupational or speech therapy if provided by the home
  health service or agency.
    (iv)   Medical   supplies,  drugs  and  medications  prescribed  by  a
  physician, and laboratory services by or on behalf of a  certified  home
  health  agency  or licensed home care services agency to the extent such
  items would have been covered under the contract if the  covered  person
  had  been  hospitalized  or  confined  in  a skilled nursing facility as
  defined in subchapter XVIII of  the  federal  Social  Security  Act,  42
  U.S.C. §§ 1395 et seq.
    (E)  For  the  purpose  of  determining  the  benefits  for  home care
  available to a covered person, each visit by a member  of  a  home  care
  team  shall  be  considered  as  one  home  care visit; the contract may
  contain a limitation on the number of home care  visits,  but  not  less
  than  forty such visits in any calendar year or in any continuous period

  of twelve months, for each person covered under the contract; four hours
  of home health aide service shall be considered as one home care visit.
    (2)  (A)  Every insurer issuing a group policy delivered or issued for
  delivery in this state which provides coverage for  in-patient  hospital
  care shall include coverage for preadmission tests performed in hospital
  facilities  prior to scheduled surgery, except that this provision shall
  not apply to a policy which 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.
    (B) Such  policy  shall  provide  benefits  for  tests  ordered  by  a
  physician  which  are  performed  in  the  out-patient  facilities  of a
  hospital as a planned preliminary to admission  of  the  patient  as  an
  in-patient for surgery in the same hospital, provided that:
    (i)  tests  are  necessary  for  and consistent with the diagnosis and
  treatment of the condition for which surgery is to be performed;
    (ii) reservations for a hospital bed and for an  operating  room  were
  made prior to the performance of the tests;
    (iii)  the  surgery  actually  takes  place  within seven days of such
  presurgical tests; and
    (iv) the patient is physically present at the hospital for the tests.
    (3) Every group policy delivered or issued for delivery in this  state
  which  provides  coverage  for  in-patient  surgical  care shall include
  coverage for a second surgical opinion by a qualified physician  on  the
  need for surgery, except that this provision shall not apply to a policy
  which  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.
    (4)  (A)  Every  group policy delivered or issued for delivery in this
  state which 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  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.
    (B)  In  this  paragraph,  an "emergency condition" means a medical or
  behavioral condition, the onset  of  which  is  sudden,  that  manifests
  itself by symptoms of sufficient severity, including severe pain, 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, 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.
    (5)  (A)  (i)  Every  group  or blanket policy delivered or issued for
  delivery in this state which  provides  hospital,  surgical  or  medical
  coverage  shall include coverage for maternity care, including hospital,
  surgical or medical care to the same extent that  coverage  is  provided
  for  illness  or disease under the policy. Such maternity care coverage,
  other than coverage for perinatal complications, shall include inpatient
  hospital coverage for mother and newborn for at least forty-eight  hours
  after  childbirth  for  any delivery other than a caesarean section, and
  for at least ninety-six hours after a caesarean section.  Such  coverage
  for  maternity  care  shall  include  the services of a midwife licensed
  pursuant to article one hundred forty of the education  law,  practicing
  consistent  with  a  written  agreement  pursuant  to section sixty-nine
  hundred fifty-one of the education law and affiliated or  practicing  in

  conjunction with a facility licensed pursuant to article twenty-eight of
  the  public  health  law,  but  no  insurer shall be required to pay for
  duplicative routine  services  actually  provided  by  both  a  licensed
  midwife and a physician.
    (ii)  Maternity  care  coverage shall also include, at minimum, parent
  education, assistance and training in breast or bottle feeding, and  the
  performance of any necessary maternal and newborn clinical assessments.
    (iii)  The  mother shall have the option to be discharged earlier than
  the time periods established in item (i) of this subparagraph.  In  such
  case,  the  inpatient  hospital  coverage must include at least one home
  care visit which shall be in addition to, rather than in  lieu  of,  any
  home  health  care  coverage available under the policy. The policy must
  cover the home care visit, which may be requested  at  any  time  within
  forty-eight  hours of the time of delivery (ninety-six hours in the case
  of caesarean section), and shall be delivered within twenty-four  hours,
  (I)  after  discharge,  or  (II)  of  the  time of the mother's request,
  whichever is later. Such home care coverage shall  be  pursuant  to  the
  policy  and  subject  to  the  provisions  of this subparagraph, and not
  subject to deductibles, coinsurance or copayments.
    (B) Coverage provided under this  paragraph  for  care  and  treatment
  during pregnancy shall include provision for not less than two payments,
  at reasonable intervals and for services rendered, for prenatal care and
  a separate payment for the delivery and postnatal care provided.
    (6)  (A)  Every  group  policy issued or delivered in this state which
  provides coverage for hospital  care  shall  not  exclude  coverage  for
  hospital  care  for  diagnosis  and  treatment  of  correctable  medical
  conditions otherwise covered by the policy solely  because  the  medical
  condition results in infertility; provided, however that:
    (i)  subject  to the provisions of subparagraph (C) of this paragraph,
  in no case shall such coverage exclude surgical  or  medical  procedures
  provided as part of such hospital care which would correct malformation,
  disease or dysfunction resulting in infertility; and
    (ii)  provided,  further  however,  that  subject to the provisions of
  subparagraph (C) of this paragraph,  in  no  case  shall  such  coverage
  exclude  diagnostic  tests  and  procedures  provided  as  part  of such
  hospital care that are necessary to determine infertility  or  that  are
  necessary  in  connection  with  any  surgical  or medical treatments or
  prescription  drug  coverage  provided  pursuant  to   this   paragraph,
  including  such  diagnostic tests and procedures as hysterosalpingogram,
  hysteroscopy, endometrial biopsy,  laparoscopy,  sono-hysterogram,  post
  coital tests, testis biopsy, semen analysis, blood tests and ultrasound;
  and
    (iii)  provided,  further  however,  every  such policy which provides
  coverage for prescription drugs shall  include,  within  such  coverage,
  coverage  for  prescription  drugs approved by the federal Food and Drug
  Administration for use in the diagnosis and treatment of infertility  in
  accordance with subparagraph (C) of this paragraph.
    (B)  Every  group  policy  issued  or  delivered  in  this state which
  provides coverage for  surgical  and  medical  care  shall  not  exclude
  coverage  for  surgical  and medical care for diagnosis and treatment of
  correctable medical conditions otherwise covered by  the  policy  solely
  because  the medical condition results in infertility; provided, however
  that:
    (i) subject to the provisions of subparagraph (C) of  this  paragraph,
  in  no  case  shall such coverage exclude surgical or medical procedures
  which would correct malformation, disease or  dysfunction  resulting  in
  infertility; and

    (ii)  provided,  further  however,  that  subject to the provisions of
  subparagraph (C) of this paragraph,  in  no  case  shall  such  coverage
  exclude  diagnostic tests and procedures that are necessary to determine
  infertility or that are necessary in connection  with  any  surgical  or
  medical  treatments  or  prescription drug coverage provided pursuant to
  this paragraph,  including  such  diagnostic  tests  and  procedures  as
  hysterosalpingogram,   hysteroscopy,  endometrial  biopsy,  laparoscopy,
  sono-hysterogram, post coital  tests,  testis  biopsy,  semen  analysis,
  blood tests and ultrasound; and
    (iii)  provided,  further  however,  every  such policy which provides
  coverage for prescription drugs shall  include,  within  such  coverage,
  coverage  for  prescription  drugs approved by the federal Food and Drug
  Administration for use in the diagnosis and treatment of infertility  in
  accordance with subparagraph (C) of this paragraph.
    (C)   Coverage  of  diagnostic  and  treatment  procedures,  including
  prescription drugs, used in the diagnosis and treatment  of  infertility
  as  required  by  subparagraphs  (A)  and (B) of this paragraph shall be
  provided in accordance with the provisions of this subparagraph.
    (i) Coverage shall be provided  for  persons  whose  ages  range  from
  twenty-one  through forty-four years, provided that nothing herein shall
  preclude the provision of coverage to persons  whose  age  is  below  or
  above such range.
    (ii)  Diagnosis  and  treatment  of infertility shall be prescribed as
  part of a physician's overall plan  of  care  and  consistent  with  the
  guidelines for coverage as referenced in this subparagraph.
    (iii)   Coverage  may  be  subject  to  co-payments,  coinsurance  and
  deductibles as may be deemed appropriate by the  superintendent  and  as
  are  consistent with those established for other benefits within a given
  policy.
    (iv) Coverage shall be limited to  those  individuals  who  have  been
  previously covered under the policy for a period of not less than twelve
  months,  provided  that for the purposes of this subparagraph "period of
  not less than twelve months" shall be  determined  by  calculating  such
  time  from  either  the  date  the  insured  was first covered under the
  existing policy or from the date the insured  was  first  covered  by  a
  previously in-force converted policy, whichever is earlier.
    (v)  Coverage  shall  not  be  required  to  include the diagnosis and
  treatment of infertility in connection with: (I) in vitro fertilization,
  gamete intrafallopian  tube  transfers  or  zygote  intrafallopian  tube
  transfers;  (II)  the  reversal  of  elective  sterilizations; (III) sex
  change procedures; (IV) cloning; or (V) medical or surgical services  or
  procedures  that  are  deemed  to  be  experimental  in  accordance with
  clinical guidelines referenced in clause (vi) of this subparagraph.
    (vi) The superintendent, in  consultation  with  the  commissioner  of
  health,   shall   promulgate   regulations  which  shall  stipulate  the
  guidelines and standards  which  shall  be  used  in  carrying  out  the
  provisions of this subparagraph, which shall include:
    (I)   The  determination  of  "infertility"  in  accordance  with  the
  standards and guidelines established and adopted by the American College
  of  Obstetricians  and  Gynecologists  and  the  American  Society   for
  Reproductive Medicine;
    (II)  The identification of experimental procedures and treatments not
  covered for the diagnosis and treatment  of  infertility  determined  in
  accordance  with the standards and guidelines established and adopted by
  the American College of Obstetricians and Gynecologists and the American
  Society for Reproductive Medicine;
    (III) The identification of  the  required  training,  experience  and
  other   standards  for  health  care  providers  for  the  provision  of

  procedures and treatments for the diagnosis and treatment of infertility
  determined in accordance with the standards and  guidelines  established
  and  adopted  by the American College of Obstetricians and Gynecologists
  and the American Society for Reproductive Medicine; and
    (IV)  The  determination  of  appropriate  medical  candidates  by the
  treating physician in  accordance  with  the  standards  and  guidelines
  established  and  adopted  by  the American College of Obstetricians and
  Gynecologists and/or the American Society for Reproductive Medicine.
    (7)(A) Every group or blanket accident  and  health  insurance  policy
  issued  or  issued  for  delivery  in  this state which provides medical
  coverage that includes coverage for physician services in a  physician's
  office  and  every  policy  which  provides  major  medical  or  similar
  comprehensive-type coverage shall include  coverage  for  the  following
  equipment  and supplies for the treatment of diabetes, if recommended or
  prescribed by a physician or other licensed health care provider legally
  authorized to prescribe under title eight of the  education  law:  blood
  glucose  monitors  and blood glucose monitors for the visually impaired,
  data management systems, test strips for  glucose  monitors  and  visual
  reading  and  urine  testing strips, insulin, injection aids, cartridges
  for the visually impaired, syringes,  insulin  pumps  and  appurtenances
  thereto, insulin infusion devices, and oral agents for controlling blood
  sugar.  In  addition, the commissioner of the department of health shall
  provide and  periodically  update  by  rule  or  regulation  a  list  of
  additional diabetes equipment and related supplies such as are medically
  necessary  for  the treatment of diabetes, for which there shall also be
  coverage.  Such  policies  shall  also  include  coverage  for  diabetes
  self-management  education  to  ensure  that  persons  with diabetes are
  educated as  to  the  proper  self-management  and  treatment  of  their
  diabetic condition, including information on proper diets. Such coverage
  for  self-management  education  and education relating to diet shall be
  limited to visits medically necessary upon the  diagnosis  of  diabetes,
  where  a  physician  diagnoses  a  significant  change  in the patient's
  symptoms  or  conditions  which  necessitate  changes  in  a   patient's
  self-management,   or   where  reeducation  or  refresher  education  is
  necessary. Such education may be provided  by  the  physician  or  other
  licensed  health  care  provider  legally  authorized to prescribe under
  title eight of the education law, or their staff, as part of  an  office
  visit  for  diabetes  diagnosis or treatment, or by a certified diabetes
  nurse  educator,  certified   nutritionist,   certified   dietitian   or
  registered  dietitian upon the referral of a physician or other licensed
  health care provider legally authorized to prescribe under  title  eight
  of the education law. Education provided by the certified diabetes nurse
  educator,  certified  nutritionist,  certified  dietitian  or registered
  dietitian  may  be  limited  to  group  settings  wherever  practicable.
  Coverage  for  self-management  education and education relating to diet
  shall also include home visits when medically necessary.
    (B) Such coverage 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) This paragraph shall not apply to a policy  which  covers  persons
  employed  in  more  than one state or the benefit structure of which was
  the subject of collective bargaining affecting persons employed in  more
  than  one  state  unless  such policy is issued under the New York state
  health insurance plan established under  article  eleven  of  the  civil
  service law or issued to or through a local government.
    (8) (A) Every group or blanket policy delivered or issued for delivery
  in  this state which provides coverage for inpatient hospital care shall
  provide such coverage for such period as is determined by the  attending

  physician  in  consultation with the patient to be medically appropriate
  for such  covered  person  undergoing  a  lymph  node  dissection  or  a
  lumpectomy for the treatment of breast cancer or a mastectomy covered by
  the  policy.  Such  coverage  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. Written notice of the availability of  such  coverage  shall  be
  delivered  to  the  policyholder  prior  to inception of such policy and
  annually thereafter.
    (B) An  insurer  providing  coverage  under  this  paragraph  and  any
  participating  entity  through  which the insurer offers health services
  shall not:
    (i) deny to a covered person eligibility, or continued eligibility, to
  enroll or to renew coverage under the terms of the policy  or  vary  the
  terms  of  the  policy  for  the  purpose or with the effect of avoiding
  compliance with this paragraph;
    (ii) provide incentives (monetary or otherwise) to encourage a covered
  person to accept less than the minimum protections available under  this
  paragraph;
    (iii)  penalize  in  any  way or reduce or limit the compensation of a
  health care practitioner for recommending or providing care to a covered
  person in accordance with this paragraph;
    (iv) provide incentives (monetary  or  otherwise)  to  a  health  care
  practitioner   relating  to  the  services  provided  pursuant  to  this
  paragraph intended to  induce  or  have  the  effect  of  inducing  such
  practitioner   to   provide  care  to  a  covered  person  in  a  manner
  inconsistent with this paragraph; or
    (v) restrict coverage for any portion of a period  within  a  hospital
  length  of  stay  required  under  this  paragraph  in a manner which is
  inconsistent with the coverage provided for  any  preceding  portion  of
  such stay.
    (C) The prohibitions in subparagraph (B) of this paragraph shall be in
  addition  to  the  provisions  of  sections  three  thousand two hundred
  thirty-one and three thousand two hundred thirty-two of this article and
  nothing in this subparagraph shall be construed to  suspend,  supersede,
  amend or otherwise modify such sections.
    (9)(A)  Every policy which provides medical, major medical, or similar
  comprehensive-type coverage must provide coverage for a  second  medical
  opinion  by  an  appropriate  specialist, including but not limited to a
  specialist affiliated with a specialty care center for the treatment  of
  cancer,  in the event of a positive or negative diagnosis of cancer or a
  recurrence of cancer or a recommendation of a course  of  treatment  for
  cancer, subject to the following:
    (i)  In  the  case  of  a  policy that requires, or provides financial
  incentives for, the insured to receive covered services from health care
  providers participating in a provider network  maintained  by  or  under
  contract  with  the  insurer,  the  policy  shall include coverage for a
  second medical opinion from a  non-participating  specialist,  including
  but  not limited to a specialist affiliated with a specialty care center
  for the treatment of cancer, when the  attending  physician  provides  a
  written  referral  to  a  non-participating specialist, at no additional
  cost to the insured  beyond  what  such  insured  would  have  paid  for
  services  from a participating appropriate specialist. Provided, however
  that nothing herein shall impair an insured's rights (if any) under  the
  policy  to  obtain  the  second medical opinion from a non-participating
  specialist without  a  written  referral,  subject  to  the  payment  of
  additional  coinsurance  (if  any)  required  by the policy for services
  provided by non-participating providers. The  insurer  shall  compensate

  the  non-participating specialist at the usual, customary and reasonable
  rate, or at a rate listed on a fee schedule filed and  approved  by  the
  superintendent which provides a comparable level of reimbursement.
    (ii)  In  the  case  of  a  policy  that  does  not  provide financial
  incentives for, and does not require, the  insured  to  receive  covered
  services  from health care providers participating in a provider network
  maintained by or under contract  with  the  insurer,  the  policy  shall
  include  coverage  for  a second medical opinion from a specialist at no
  additional cost to the insured beyond what the insured would  have  paid
  for comparable services covered under the policy.
    (iii)   Such  coverage  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, and, where applicable, consistent with the provisions of clauses
  (i) and (ii) of this subparagraph.
    Nothing in this paragraph shall eliminate  or  diminish  an  insurer's
  obligation  to comply with the provisions of section four thousand eight
  hundred four of this chapter where applicable.  Written  notice  of  the
  availability  of  such  coverage  shall be delivered to the policyholder
  prior to the inception of such policy and annually thereafter.
    (B) An  insurer  providing  coverage  under  this  paragraph  and  any
  participating  entity  through  which  an insurer offers health services
  shall not:
    (i) deny to a covered person eligibility, or continued eligibility, to
  enroll or to renew coverage under the terms of the policy  or  vary  the
  terms  of  the  policy  for  the  purpose or with the effect of avoiding
  compliance with this paragraph;
    (ii) provide incentives (monetary or otherwise) to encourage a covered
  person to accept less than the minimum protections available under  this
  paragraph;
    (iii)  penalize  in  any  way or reduce or limit the compensation of a
  health care practitioner for recommending or providing care to a covered
  person in accordance with this paragraph; or
    (iv) provide incentives (monetary  or  otherwise)  to  a  health  care
  practitioner   relating  to  the  coverage  provided  pursuant  to  this
  paragraph intended to  induce  or  have  the  effect  of  inducing  such
  practitioner   to   provide  care  to  a  covered  person  in  a  manner
  inconsistent with this paragraph.
    (C) The prohibitions in subparagraph (B) of this paragraph shall be in
  addition to the  provisions  of  sections  three  thousand  two  hundred
  thirty-one and three thousand two hundred thirty-two of this article and
  nothing  in  this subparagraph shall be construed to suspend, supersede,
  amend or otherwise modify such sections.
    (10)(A) Every group or blanket policy delivered or issued for delivery
  in  this  state  which  provides  medical,  major  medical,  or  similar
  comprehensive-type  coverage  shall  provide  the following coverage for
  breast reconstruction surgery after a mastectomy:
    (i) all stages of reconstruction of the breast on which the mastectomy
  has been performed; and
    (ii) surgery and reconstruction of  the  other  breast  to  produce  a
  symmetrical appearance;
  in  the  manner determined by the attending physician and the patient to
  be appropriate. Such coverage may be subject to annual  deductibles  and
  coinsurance   provisions   as   may   be   deemed   appropriate  by  the
  superintendent and as are consistent with those  established  for  other
  benefits  within  a  given policy. Written notice of the availability of
  such coverage shall be delivered to the policyholder prior to  inception
  of such policy and annually thereafter.

    (B)  An  insurer  providing  coverage  under  this  paragraph  and any
  participating entity through which the insurer  offers  health  services
  shall not:
    (i) deny to a covered person eligibility, or continued eligibility, to
  enroll  or  to  renew coverage under the terms of the policy or vary the
  terms of the policy for the purpose  or  with  the  effect  of  avoiding
  compliance with this paragraph;
    (ii) provide incentives (monetary or otherwise) to encourage a covered
  person  to accept less than the minimum protections available under this
  paragraph;
    (iii) penalize in any way or reduce or limit  the  compensation  of  a
  health care practitioner for recommending or providing care to a covered
  person in accordance with this paragraph;
    (iv)  provide  incentives  (monetary  or  otherwise)  to a health care
  practitioner  relating  to  the  services  provided  pursuant  to   this
  paragraph  intended  to  induce  or  have  the  effect  of inducing such
  practitioner  to  provide  care  to  a  covered  person  in   a   manner
  inconsistent with this paragraph; or
    (v)  restrict  coverage  for any portion of a period within a hospital
  length of stay required under  this  paragraph  in  a  manner  which  is
  inconsistent  with  the  coverage  provided for any preceding portion of
  such stay.
    (C) The prohibitions in this paragraph shall be  in  addition  to  the
  provisions  of  sections three thousand two hundred thirty-one and three
  thousand two hundred thirty-two of this  article  and  nothing  in  this
  paragraph  shall  be construed to suspend, supersede, amend or otherwise
  modify such sections.
    * (11) Every policy which provides  coverage  for  prescription  drugs
  shall include coverage for the cost of enteral formulas for home use for
  which  a  physician  or  other  licensed  health  care  provider legally
  authorized to prescribe under title  eight  of  the  education  law  has
  issued  a written order. Such written order shall state that the enteral
  formula is clearly medically necessary and has been proven effective  as
  a  disease-specific  treatment  regimen for those individuals who are or
  will become  malnourished  or  suffer  from  disorders,  which  if  left
  untreated,  cause  chronic  physical  disability,  mental retardation or
  death. Specific diseases for which enteral  formulas  have  been  proven
  effective  shall  include, but are not limited to, inherited diseases of
  amino-acid or organic acid metabolism; Crohn's Disease; gastroesophageal
  reflux with failure to thrive; disorders  of  gastrointestinal  motility
  such as chronic intestinal pseudo-obstruction; and multiple, severe food
  allergies  which  if  left  untreated will cause malnourishment, chronic
  physical disability, mental retardation or death. Enteral formulas which
  are medically necessary and taken under written order from  a  physician
  for  the  treatment  of  specific  diseases  shall be distinguished from
  nutritional supplements taken electively. Coverage for certain inherited
  diseases of  amino  acid  and  organic  acid  metabolism  shall  include
  modified  solid  food  products  that  are  low protein or which contain
  modified protein which are medically necessary, and  such  coverage  for
  such  modified  solid  food  products  for  any calendar year or for any
  continuous period of twelve months for any insured individual shall  not
  exceed two thousand five hundred dollars.
    * NB There are 2 par (11)'s
    * (11)(A) Every policy which is a "managed care product" as defined in
  subparagraph  (D) of this paragraph that includes coverage for physician
  services in a physician's office, and every policy which is  a  "managed
  care  product" that provides major medical or similar comprehensive-type
  coverage shall include coverage for chiropractic  care,  as  defined  in

  section  six  thousand  five  hundred  fifty-one  of  the education law,
  provided by a doctor of chiropractic licensed pursuant  to  article  one
  hundred  thirty-two  of  the  education  law,  in  connection  with  the
  detection  or  correction  by  manual  or mechanical means of structural
  imbalance, distortion or subluxation in the human body for  the  purpose
  of  removing  nerve  interference,  and  the effects thereof, where such
  interference is the result of or related to distortion, misalignment  or
  subluxation  of  or  in the vertebral column. However, chiropractic care
  and services may be subject to  reasonable  deductible,  co-payment  and
  co-insurance  amounts,  reasonable fee or benefit limits, and reasonable
  utilization review, provided that any such amounts, limits  and  review:
  (a)  shall  not  function to direct treatment in a manner discriminative
  against chiropractic care, and (b) individually and  collectively  shall
  be  no  more  restrictive than those applicable under the same policy to
  care  or  services  provided  by  other  health  professionals  in   the
  diagnosis,  treatment  and management of the same or similar conditions,
  injuries,  complaints,  disorders  or  ailments,   even   if   differing
  nomenclature  is  used  to  describe  the  condition, injury, complaint,
  disorder or ailment. Nothing herein  contained  shall  be  construed  as
  impeding  or preventing either the provision or coverage of chiropractic
  care and services by duly licensed doctors of chiropractic,  within  the
  lawful scope of chiropractic practice, in hospital facilities on a staff
  or employee basis.
    (C)  Every  policy which includes coverage for physician services in a
  physician's office, and every policy which  provides  major  medical  or
  similar comprehensive-type coverage, other than a "managed care product"
  as defined in subparagraph (D) of this paragraph, shall provide coverage
  for  chiropractic  care, as defined in section six thousand five hundred
  fifty-one of the education law, provided by  a  doctor  of  chiropractic
  licensed  pursuant  to  article  one hundred thirty-two of the education
  law, in connection  with  the  detection  or  correction  by  manual  or
  mechanical  means  of structural imbalance, distortion or subluxation in
  the human body for the purpose of removing nerve interference,  and  the
  effects  thereof, where such interference is the result of or related to
  distortion, misalignment or subluxation of or in the  vertebral  column.
  However,  chiropractic  care  and  services may be subject to reasonable
  deductible, co-payment  and  co-insurance  amounts,  reasonable  fee  or
  benefit  limits,  and  reasonable  utilization review, provided that any
  such amounts, limits and  review:  (a)  shall  not  function  to  direct
  treatment  in a manner discriminative against chiropractic care, and (b)
  individually and collectively shall be no more  restrictive  that  those
  applicable  under  the same policy to care or services provided by other
  health professionals in the diagnosis, treatment and management  of  the
  same or similar conditions, injuries, complaints, disorders or ailments,
  even  if  differing  nomenclature  is  used  to  describe the condition,
  injury, complaint, disorder or ailment. Nothing herein  contained  shall
  be  construed as impeding or preventing either the provision or coverage
  of  chiropractic  care  and  services  by  duly  licensed   doctors   of
  chiropractic,  within  the  lawful  scope  of  chiropractic practice, in
  hospital facilities on a staff or employee basis.
    (D) For purposes of this paragraph, a  "managed  care  product"  shall
  mean  a policy which requires that medical or other health care services
  covered under  the  policy,  other  than  emergency  care  services,  be
  provided  by,  or  pursuant to a referral from, a primary care provider,
  and that services provided pursuant to such a referral be rendered by  a
  health  care  provider  participating  in  the  insurer's  managed  care
  provider network. In addition, a managed care product  shall  also  mean
  the  in-network  portion  of  a  contract which requires that medical or

  other health care  services  covered  under  the  contract,  other  than
  emergency care services, be provided by, or pursuant to a referral from,
  a  primary  care provider, and that services provided pursuant to such a
  referral  be  rendered  by  a  health care provider participating in the
  insurer's managed care provider network, in order for the insured to  be
  entitled to the maximum reimbursement under the contract.
    (E)  The  coverage required by this paragraph shall not be abridged by
  any regulation promulgated by the superintendent.
    * NB There are 2 par (11)'s
    (12) No policy of group  or  blanket  accident  and  health  insurance
  delivered or issued for delivery in this state shall exclude coverage of
  a  health  care service, as defined in paragraph two of such subdivision
  (e) of section four thousand nine hundred of this chapter,  rendered  or
  proposed  to be rendered to an insured on the basis that such service is
  experimental or investigational, is rendered as part of a clinical trial
  as defined in subsection (b-2) of section  forty-nine  hundred  of  this
  chapter,   or   a   prescribed   pharmaceutical  product  referenced  in
  subparagraph  (B)  of  paragraph  two  of  subsection  (e)  of   section
  forty-nine hundred of this chapter provided that coverage of the patient
  costs  of  such  service  has  been  recommended  for  the insured by an
  external appeal agent upon an appeal conducted pursuant to  subparagraph
  (B)  of  paragraph  four of subsection (b) of section four thousand nine
  hundred fourteen of this chapter.  The  determination  of  the  external
  appeal  agent  shall  be  binding  on  the parties. For purposes of this
  paragraph, patient costs shall have the same meaning as  such  term  has
  for  purposes of subparagraph (B) of paragraph four of subsection (b) of
  section four thousand nine hundred fourteen of this  chapter;  provided,
  however,  that  coverage  for the services required under this paragraph
  shall  be  provided  subject  to  the  terms  and  conditions  generally
  applicable to other benefits provided under the policy.
    (13) Every group or blanket policy delivered or issued for delivery in
  this  state  which  provides major medical or similar comprehensive-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  paragraph,  the
  insurer  or  health maintenance organization shall adopt standards which
  include the criteria of the federal 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 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 absorptiometry.
    (B)  for purposes 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  qualifying  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
  osteoporosis; 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.
    Such coverage 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.
    (14) No group or blanket policy delivered or issued  for  delivery  in
  this   state   which   provides   medical,   major  medical  or  similar
  comprehensive-type coverage shall exclude coverage for services  covered
  under  such  policy  when  provided  by  a comprehensive care center for
  eating disorders pursuant to article twenty-seven-J of the public health
  law;  provided,  however,  that  reimbursement  under  such  policy  for
  services  provided through such comprehensive care centers shall, to the
  extent possible and practicable, be structured in a manner to facilitate
  the individualized, comprehensive and integrated  plans  of  care  which
  such  centers'  network  of  practitioners and providers are required to
  provide.
    * (15)(A) No group or blanket managed  care  health  insurance  policy
  that  provides  coverage  for  hospital,  medical or surgical care shall
  provide that services of a participating hospital  will  be  covered  as
  out-of-network  services  solely  on  the  basis  that  the  health care
  provider admitting or  rendering  services  to  the  insured  is  not  a
  participating provider.
    (B)  No  group  or  blanket  managed care health insurance policy that
  provides coverage for hospital, medical or surgical care  shall  provide
  that services of a participating health care provider will be covered as
  out-of-network  services  solely  on  the  basis  that  the services are
  rendered in a non-participating hospital.
    (C) For purposes of this paragraph, a  "health  care  provider"  is  a
  health  care  professional licensed, registered or certified pursuant to
  title  eight  of  the  education  law  or  a  health  care  professional
  comparably licensed, registered or certified by another state.
    (D)  For  purposes of this paragraph, a "managed care health insurance
  policy" is a policy  that  requires  that  services  be  provided  by  a
  provider participating in the insurer's network in order for the insured
  to receive the maximum level of reimbursement under the policy.
    * NB Effective January 1, 2010
    (l)  (1)  Every  insurer  delivering a group policy or issuing a group
  policy for delivery in this state which provides coverage  supplementing
  part  A  and  part  B of subchapter XVIII of the federal Social Security
  Act, 42 U.S.C. §§ 1395 et seq, must make available and, if requested  by
  the  policyholder,  provide  coverage  of  supplemental home care visits
  beyond those provided by part A and part B,  sufficient  to  produce  an
  aggregate  coverage  of  three  hundred  sixty-five home care visits per
  policy year. Such coverage shall be  provided  pursuant  to  regulations
  prescribed  by the superintendent. Written notice of the availability of
  such coverage shall be delivered to the policyholder prior to  inception
  of  such  group  policy and annually thereafter, except that this notice
  shall not be  required  where  a  policy  covers  two  hundred  or  more
  employees  or  where the benefit structure was the subject of collective
  bargaining affecting persons who are employed in more than one state.
    (2) (A) Every insurer delivering a group policy  or  issuing  a  group
  policy  for  delivery,  in  this  state,  which  provides  coverage  for
  in-patient hospital care must make available, and if  requested  by  the
  policyholder,  provide  coverage  for  care  in  a nursing home. Written
  notice of the availability of such coverage shall be  delivered  to  the
  policyholder  prior  to  inception  of  such  group  policy and annually

  thereafter, except that this notice shall not be required where a policy
  covers two hundred or more employees or where the benefit structure  was
  the  subject of collective bargaining affecting persons who are employed
  in more than one state.
    (B)  Such coverage shall be made available at the inception of all new
  policies and, with respect to all other policies at any anniversary date
  of the policy subject to evidence of insurability.
    (C) In this paragraph, care in a nursing home means the continued care
  and treatment of a covered person who is under the care of  a  physician
  but only if:
    (i)  the  care  is  provided  in  a nursing home as defined in section
  twenty-eight hundred one of the public health law or a  skilled  nursing
  facility  as  defined in subchapter XVIII of the federal Social Security
  Act, 42 U.S.C. §§ 1395 et seq;
    (ii) the covered person has been in a hospital for at least three days
  immediately preceding admittance to the  nursing  home  or  the  skilled
  nursing facility; and
    (iii) further hospitalization would otherwise be necessary.
    (D)  In  determining  the total days of coverage for nursing home care
  the aggregate of the number of covered days of care in  a  hospital  and
  the  number  of covered days of care in a nursing home, with two days of
  care in a nursing home equivalent to one day of care in a hospital, need
  not exceed the number of covered days of hospital  care  provided  under
  the contract in a benefit period.
    (E) The level of benefits to be provided for nursing home care must be
  reasonably related to the benefits provided for hospital care.
    (3)  (A)  Every  insurer  delivering a group policy or issuing a group
  policy  for  delivery,  in  this  state,  which  provides  coverage  for
  in-patient  hospital  care  must  make available and if requested by the
  policyholder provide coverage to residents in this state for  ambulatory
  care  in  hospital  out-patient  facilities, as a hospital is defined in
  section twenty-eight hundred one of the public health law, or subchapter
  XVIII of the federal Social Security Act, 42 U.S.C. §§ 1395 et seq,  and
  physicians' offices. Written notice of the availability of such coverage
  shall  be delivered to the policyholder prior to inception of such group
  policy and annually thereafter, except that this  notice  shall  not  be
  required  where  a  policy covers two hundred or more employees or where
  the benefit structure was the subject of collective bargaining affecting
  persons who are employed in more than one state.
    (B) In this paragraph:
    (i)  "Ambulatory  care  in  hospital  out-patient  facilities"   means
  services    for   diagnostic   X-rays,   laboratory   and   pathological
  examinations, physical and occupational therapy and  radiation  therapy,
  and   services   and   medications   used   for  nonexperimental  cancer
  chemotherapy and cancer hormone therapy, provided that such services and
  medications are related to and necessary for the treatment or  diagnosis
  of  the  patient's illness or injury, are ordered by a physician and, in
  the case of physical therapy services, are to be furnished in connection
  with the same illness for which the patient had been hospitalized or  in
  connection  with  surgical  care,  but  in  no  event  need benefits for
  physical therapy be provided which commences more than six months  after
  discharge from a hospital or the date surgical care was rendered, and in
  no  event  need  benefits  for  physical therapy be provided after three
  hundred sixty-five days from the date of discharge from  a  hospital  or
  the date surgical care was rendered.
    (ii) "Ambulatory  care  in  physicians'  offices"  means  services for
  diagnostic  X-rays,  radiation  therapy,  laboratory  and   pathological
  examinations,  and  services  and  medications  used for nonexperimental

  cancer chemotherapy and  cancer  hormone  therapy,  provided  that  such
  services  and medications are related to and necessary for the treatment
  or diagnosis of the patient's  illness  or  injury,  and  ordered  by  a
  physician.
    (C)  Such coverage shall be made available at the inception of all new
  policies and, with respect to  policies  issued  before  January  first,
  nineteen  hundred  eighty-three,  at  the  first annual anniversary date
  thereafter, without evidence  of  insurability  and  at  any  subsequent
  annual anniversary date subject to evidence of insurability.
    (4)  (A)  Every  insurer  delivering a group policy or issuing a group
  policy for delivery, in this state,  which  provides  reimbursement  for
  psychiatric or psychological services or for the diagnosis and treatment
  of  mental, nervous or emotional disorders and ailments, however defined
  in such policy, by physicians, psychiatrists or psychologists, must make
  available and if requested by the policyholder provide the same coverage
  to insureds for such services when  performed  by  a  licensed  clinical
  social  worker,  within  the lawful scope of his or her practice, who is
  licensed pursuant to article one hundred  fifty-four  of  the  education
  law.  Written  notice  of  the  availability  of  such coverage shall be
  delivered to the policyholder prior to inception of  such  group  policy
  and  annually  thereafter, except that this notice shall not be required
  where a policy covers two hundred or more employees or where the benefit
  structure was the subject of collective bargaining affecting persons who
  are employed in more than one state.
    (B) The state board for social work  shall  maintain  a  list  of  all
  licensed  clinical social workers qualified for reimbursement under this
  paragraph.
    (C) Such coverage shall be made available at the inception of all  new
  policies  and,  with  respect  to  all  other policies at any subsequent
  annual  anniversary  date  of  the  policy  subject   to   evidence   of
  insurability.
    (D)  In  addition  to  the  requirements  of  subparagraph (A) of this
  paragraph, every insurer issuing a group policy  for  delivery  in  this
  state which policy provides reimbursement to insureds for psychiatric or
  psychological  services  or  for  the diagnosis and treatment of mental,
  nervous or emotional disorders and ailments,  however  defined  in  such
  policy,  by physicians, psychiatrists or psychologists, must provide the
  same coverage to insureds for such services when performed by a licensed
  clinical social worker, within the lawful scope of his or her  practice,
  who  is  licensed  pursuant to subdivision two of section seven thousand
  seven hundred four of the education  law  and  in  addition  shall  have
  either  (i)  three or more additional years experience in psychotherapy,
  which for the purposes of this subparagraph shall mean the use of verbal
  methods in interpersonal relationships with the intent  of  assisting  a
  person   or   persons   to  modify  attitudes  and  behavior  which  are
  intellectually, socially or emotionally maladaptive, under  supervision,
  satisfactory to the state board for social work, in a facility, licensed
  or  incorporated  by  an  appropriate governmental department, providing
  services for diagnosis or treatment  of  mental,  nervous  or  emotional
  disorders or ailments, or (ii) three or more additional years experience
  in  psychotherapy under the supervision, satisfactory to the state board
  for  social  work,  of  a  psychiatrist,  a  licensed   and   registered
  psychologist   or  a  licensed  clinical  social  worker  qualified  for
  reimbursement pursuant to subsection (h) of this  section,  or  (iii)  a
  combination  of  the experience specified in items (i) and (ii) totaling
  three years, satisfactory to the state board for social work. The  state
  board  for  social  work  shall maintain a list of all licensed clinical
  social workers qualified for reimbursement under this subparagraph.

    (5) (A) Every insurer delivering a group or school blanket  policy  or
  issuing  a  group  or school blanket policy for delivery, in this state,
  which provides coverage for inpatient  hospital  care  or  coverage  for
  physician  services  shall  provide  as  part of such policy broad-based
  coverage for the diagnosis and treatment of mental, nervous or emotional
  disorders or ailments, however defined in such policy, at least equal to
  the coverage provided for other health conditions and:
    (i)  where  the  policy provides coverage for inpatient hospital care,
  benefits for inpatient care in a hospital as defined by subdivision  ten
  of section 1.03 of the mental hygiene law, which benefits may be limited
  to  not  less than thirty days of active treatment in any contract year,
  plan year or calendar year, and benefits for outpatient care provided in
  a facility issued an operating certificate by the commissioner of mental
  health pursuant to the provisions of article thirty-one  of  the  mental
  hygiene  law,  or in a facility operated by the office of mental health,
  which benefits may be limited to not less  than  twenty  visits  in  any
  contract  year,  plan  year  or  calendar  year.  Benefits  for  partial
  hospitalization program services shall  be  provided  as  an  offset  to
  covered  inpatient days at a ratio of two partial hospitalization visits
  to one inpatient day of treatment.
    (ii) where the policy provides coverage  for  physician  services,  it
  shall include benefits for outpatient care provided by a psychiatrist or
  psychologist  licensed  to  practice  in this state, a licensed clinical
  social  worker  who  meets  the  requirements  of  subparagraph  (D)  of
  paragraph  four  of  this  subsection,  or a professional corporation or
  university faculty practice corporation thereof. Such  benefits  may  be
  limited  to not less than twenty visits in any contract year, plan year,
  or calendar year.
    (iii) Coverage required  by  this  paragraph  may  be  provided  on  a
  contract  year, plan year or calendar year basis and shall be consistent
  with the provision of other benefits under the policy. Such coverage may
  be subject to annual deductibles, co-pays  and  coinsurance  as  may  be
  deemed  appropriate  by  the superintendent and shall be consistent with
  those imposed on other benefits under the policy. In the  event  that  a
  policy  provides coverage for both inpatient hospital care and physician
  services, the aggregate of the benefits  for  outpatient  care  obtained
  under  this  paragraph  may be limited to not less than twenty visits in
  any contract year, plan year or calendar year.
    (iv) In this paragraph, "active treatment" means  treatment  furnished
  in  conjunction  with  inpatient  confinement  for  mental,  nervous  or
  emotional disorders or ailments that meet standards prescribed  pursuant
  to the regulations of the commissioner of mental health.
    (B)  (i)  Every insurer delivering a group or school blanket policy or
  issuing a group or school blanket policy for delivery,  in  this  state,
  which  provides  coverage  for  inpatient  hospital care or coverage for
  physician services, shall provide comparable  coverage  for  adults  and
  children  with  biologically  based  mental illness. Such group policies
  issued or delivered in this state shall  also  provide  such  comparable
  coverage for children with serious emotional disturbances. Such coverage
  shall  be  provided  under the terms and conditions otherwise applicable
  under  the  policy,  including  network   limitations   or   variations,
  exclusions,  co-pays,  coinsurance,  deductibles  or other specific cost
  sharing mechanisms. Provided  further,  where  a  policy  provides  both
  in-network  and out-of-network benefits, the out-of-network benefits may
  have different coinsurance, co-pays, or deductibles, than the in-network
  benefits, regardless of whether the policy is written under one  license
  or two licenses.

    (ii)  For  purposes  of  this  paragraph, the term "biologically based
  mental illness" means a mental, nervous, or emotional condition that  is
  caused by a biological disorder of the brain and results in a clinically
  significant, psychological syndrome or pattern that substantially limits
  the  functioning of the person with the illness. Such biologically based
  mental illnesses are defined as schizophrenia/psychotic disorders, major
  depression, bipolar  disorder,  delusional  disorders,  panic  disorder,
  obsessive compulsive disorders, bulimia, and anorexia.
    (C)  For  purposes  of this paragraph, the term "children with serious
  emotional disturbances" means persons under the age  of  eighteen  years
  who  have  diagnoses of attention deficit disorders, disruptive behavior
  disorders, or pervasive development disorders, and where there  are  one
  or more of the following:
    (i)    serious    suicidal    symptoms   or   other   life-threatening
  self-destructive behaviors;
    (ii) significant psychotic symptoms (hallucinations, delusion, bizarre
  behaviors);
    (iii) behavior caused by emotional disturbances that placed the  child
  at risk of causing personal injury or significant property damage; or
    (iv)  behavior  caused by emotional disturbances that placed the child
  at substantial risk of removal from the household.
    (D) (i) The provisions of subparagraph (B) of this paragraph shall not
  apply to any group purchaser with fifty or fewer  employees  that  is  a
  policyholder  of  a  policy  that  is  subject to the provisions of this
  section; provided however that an insurer must make  available,  and  if
  requested  by such group purchaser, provide the coverage as specified in
  subparagraph (B) of this paragraph. Written notice of  the  availability
  of  the  coverage  shall  be  delivered  to  the  policyholder  prior to
  inception of the group policy and annually thereafter.
    (ii) The superintendent shall develop and implement a  methodology  to
  fully  cover  the  cost  to  any  such group purchaser for providing the
  coverage  required  in  subparagraph  (A)  of   this   paragraph.   Such
  methodology  shall  be  financed  from  funds from the General Fund that
  shall be made available to the superintendent for such purpose.
    (E) (i) Nothing in this paragraph shall be construed  to  prevent  the
  medical  management  or  utilization  review  of mental health benefits,
  including  the  use  of   prospective,   concurrent   or   retrospective
  utilization review, preauthorization, and appropriateness criteria as to
  the level and intensity of treatment applicable to behavioral health.
    (ii)  Nothing in this paragraph shall be construed to prevent a policy
  from providing services through a network of participating providers who
  shall meet certain requirements for  participation,  including  provider
  credentialing.
    (iii)  Nothing  in  this  paragraph  shall  be  construed to require a
  policy:  (I) to cover mental health benefits or services for individuals
  who are  presently  incarcerated,  confined  or  committed  to  a  local
  correctional  facility  or  a  prison, or a custodial facility for youth
  operated by the office of children and family services; or (II) to cover
  services solely because such services are ordered by a court.
    (iv) Nothing in this paragraph shall be deemed to require a policy  to
  cover benefits or services deemed cosmetic in nature on the grounds that
  changing  or  improving  an  individual's appearance is justified by the
  individual's mental health needs.
    (6) (A) Every insurer delivering a group or school blanket  policy  or
  issuing  a  group  or school blanket policy for delivery, in this state,
  which provides coverage for inpatient hospital care must make  available
  and,  if  requested  by  the  policyholder,  provide  coverage  for  the
  diagnosis and treatment  of  chemical  abuse  and  chemical  dependence,

  however  defined  in  such  policy,  provided,  however,  that  the term
  chemical abuse shall mean and include alcohol and  substance  abuse  and
  chemical  dependence  shall  mean  and  include alcoholism and substance
  dependence,  however  defined  in  such  policy.  Written  notice of the
  availability of such coverage shall be  delivered  to  the  policyholder
  prior  to inception of such group policy and annually thereafter, except
  that this notice shall not be required where a policy covers two hundred
  or more employees or where the benefit  structure  was  the  subject  of
  collective  bargaining  affecting  persons who are employed in more than
  one state.
    (B) Such coverage shall be at least equal to the following:
    (i) with respect to benefits for detoxification as  a  consequence  of
  chemical   dependence,   inpatient   benefits   in   a   hospital  or  a
  detoxification facility may not be limited to less than  seven  days  of
  active treatment in any calendar year; and
    (ii)  with  respect  to  benefits  for  rehabilitation  services, such
  benefits may not be limited to less than thirty days of  inpatient  care
  in any calendar year.
    (C) Such coverage may be limited to facilities in New York state which
  are  certified  by the office of alcoholism and substance abuse services
  and, in other states,  to  those  which  are  accredited  by  the  joint
  commission  on accreditation of hospitals as alcoholism, substance abuse
  or chemical dependence treatment programs.
    (D) Such coverage shall be made available at the inception of all  new
  policies  and with respect to all other policies at any anniversary date
  of the policy subject to evidence of insurability.
    (E)  Such  coverage  may  be  subject  to   annual   deductibles   and
  co-insurance  as may be deemed appropriate by the superintendent and are
  consistent with those imposed on other benefits within a  given  policy.
  Further,  each  insurer shall report to the superintendent each year the
  number of contract holders to  whom  it  has  issued  policies  for  the
  inpatient  treatment  of chemical dependence, and the approximate number
  of persons covered by such policies.
    (F) Such coverage shall not replace, restrict  or  eliminate  existing
  coverage provided by the policy.
    (7)  Every  insurer  delivering  a  group  or school blanket policy or
  issuing a group or school blanket policy  for  delivery  in  this  state
  which  provides  coverage  for  inpatient  hospital  care  must  provide
  coverage for at least sixty outpatient visits in any calendar  year  for
  the diagnosis and treatment of chemical dependence of which up to twenty
  may be for family members, except that this provision shall not apply to
  a  policy  which  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. Such coverage
  may  be  limited to facilities in New York state certified by the office
  of alcoholism and substance abuse services or licensed by such office as
  outpatient clinics or medically supervised  ambulatory  substance  abuse
  programs  and,  in  other  states,  to those which are accredited by the
  joint commission on accreditation of hospitals as alcoholism or chemical
  dependence treatment programs. Such coverage may be  subject  to  annual
  deductibles  and  co-insurance  as  may  be  deemed  appropriate  by the
  superintendent and are consistent with those imposed on  other  benefits
  within  a  given  policy.  Such coverage shall not replace, restrict, or
  eliminate existing coverage provided by the policy. Except as  otherwise
  provided  in  the applicable policy or contract, no insurer delivering a
  group or school blanket policy or issuing  a  group  or  school  blanket
  policy  providing  coverage  for  alcoholism or substance abuse services
  pursuant to this section shall deny coverage  to  a  family  member  who

  identifies  themself  as  a family member of a person suffering from the
  disease of alcoholism, substance abuse or chemical  dependency  and  who
  seeks  treatment  as  a  family  member  who is otherwise covered by the
  applicable  policy  or  contract  pursuant to this section. The coverage
  required by this paragraph shall include treatment as  a  family  member
  pursuant  to  such  family members' own policy or contract provided such
  family member (i) does not exceed the allowable number of family  visits
  provided  by the applicable policy or contract pursuant to this section,
  and (ii) is otherwise entitled to coverage pursuant to this section  and
  such family members' applicable policy or contract.
    (8)  (A)  Every  insurer  issuing  a group policy for delivery in this
  state    which    provides    medical,    major-medical    or    similar
  comprehensive-type  coverage  must provide coverage for the provision of
  preventive and primary care services.
    (B) In this paragraph, preventive and primary care services means  the
  following  services rendered to a dependent 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
  association 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
  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
  laboratory; 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
  hepatitis  b  which  meet  the  standards  approved by the United States
  public health service for such biological products.
    (C) Such coverage shall not be subject to  annual  deductibles  and/or
  coinsurance.
    (D)  Such  coverage  shall not restrict or eliminate existing coverage
  provided by the policy.
    (9) Every insurer issuing a group policy for delivery  in  this  state
  which  policy  provides coverage for any service within the lawful scope
  of practice of a duly licensed registered professional nurse, must  make
  available,   and   if   requested   by   the  contract  holder,  provide
  reimbursement for such service when such service is performed by a  duly
  licensed   registered   professional   nurse   provided,  however,  that
  reimbursement shall not be made for  nursing  services  provided  to  an
  insured  in  a  general  hospital,  nursing home or a facility providing

  health  related  services,  as  such  terms  are  defined   in   section
  twenty-eight  hundred one of the public health law, or in a facility, as
  such term is defined in subdivision six of section 1.03  of  the  mental
  hygiene law, or in a physician's office. Such coverage may be subject to
  annual  deductibles and co-insurance as may be deemed appropriate by the
  superintendent and are consistent with those imposed on  other  benefits
  within  a  given  policy.  Such  coverage shall not replace, restrict or
  eliminate existing coverage provided by the  policy.  Coverage  for  the
  services  of  a  duly  licensed  registered  professional  nurse need be
  provided only if the  nature  of  the  patient's  illness  or  condition
  requires  nursing  care  which can appropriately be provided by a person
  with the education and professional skill of a  registered  professional
  nurse  and  the  nursing  care  is  necessary  in  the  treatment of the
  patient's illness or condition. Written notice of  the  availability  of
  such  coverage shall be delivered to the policyholder prior to inception
  of such group policy and annually thereafter, except  that  this  notice
  shall  not  be  required  where  a  policy  covers  two  hundred or more
  employees or where the benefit structure was the subject  of  collective
  bargaining affecting persons who are employed in more than one state.
    (10)  (A)  Every  insurer  issuing a group policy for delivery in this
  state which provides coverage for  inpatient  hospital  care  must  make
  available  and  if  requested  by  the policyholder provide coverage for
  hospice care.  Written notice of the availability of such coverage shall
  be delivered to the policyholder prior to inception of such group policy
  and annually thereafter, except that this notice shall not  be  required
  where a policy covers two hundred or more employees or where the benefit
  structure was the subject of collective bargaining affecting persons who
  are employed in more than one state.
    (B)  For  the  purposes of this paragraph, hospice care shall mean the
  care and treatment of a covered person who has been  certified  by  such
  person's  primary attending physician as having a life expectancy of six
  months or less and which is provided by a hospice organization certified
  pursuant to article forty of the public health law or  under  a  similar
  certification  process  required  by  the  state  in  which  the hospice
  organization is located.
    (C) Hospice care coverage shall be at least equal to: (i) a  total  of
  two  hundred  ten days of coverage beginning with the first day on which
  care is provided, for inpatient hospice  care  in  a  hospice  or  in  a
  hospital  and home care and outpatient services provided by the hospice,
  including  drugs  and  medical  supplies,  and  (ii)  five  visits   for
  bereavement  counseling  services,  either before or after the insured's
  death, provided to the family of the terminally ill insured.
    (D) Such coverage shall be made available at the inception of all  new
  policies  and, with respect to policies issued before the effective date
  of this provision, at the  first  annual  anniversary  date  thereafter,
  without   evidence   of   insurability  and  at  any  subsequent  annual
  anniversary date subject to evidence of insurability.
    (E) Such coverage may be subject to annual deductibles and coinsurance
  as may be deemed appropriate by the superintendent  and  are  consistent
  with those imposed on other benefits within a given policy period.
    (11) (A) Every insurer delivering a group or blanket policy or issuing
  a  group  or  blanket  policy  for delivery in this state which 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 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  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.
    (11-a) (A) Every policy delivered or issued for delivery in this state
  which  provides  medical  coverage  that includes coverage for physician
  services in a physician's office and every policy which  provides  major
  medical  or  similar comprehensive-type coverage shall provide, upon the
  prescription of a health care provider legally authorized  to  prescribe
  under  title  eight  of  the  education  law, the following coverage for
  diagnostic screening for prostatic cancer:
    (i) standard diagnostic testing  including,  but  not  limited  to,  a
  digital  rectal  examination and a prostate-specific antigen test at any
  age for men having a prior history of prostate cancer; and
    (ii) an annual standard  diagnostic  examination  including,  but  not
  limited to, a digital rectal examination and a prostate-specific antigen
  test  for  men  age  fifty and over who are asymptomatic and for men age
  forty and over with  a  family  history  of  prostate  cancer  or  other
  prostate cancer risk factors.
    (B) Such coverage 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.
    (12) (A) Every insurer delivering a group or blanket policy or issuing
  a  group  or  blanket  policy  for delivery in this state which provides
  coverage  for  prescribed  drugs  approved  by   the   food   and   drug
  administration  of  the  United  States  government for the treatment of
  certain types of cancer shall not exclude coverage of any such  drug  on
  the basis that such drug has been prescribed for the treatment of a type
  of  cancer for which the drug has not been approved by the food and drug
  administration. Provided, however, that such drug must be recognized for
  treatment of the specific type of cancer for which  the  drug  has  been
  prescribed in one of the following established reference compendia:
    (i) the American Medical Association Drug Evaluations;
    (ii) the American Hospital Formulary Service Drug Information; or
    (iii)  the United States Pharmacopeia Drug Information; or recommended
  by review  article  or  editorial  comment  in  a  major  peer  reviewed
  professional journal.
    (B)  Notwithstanding  the provisions of this paragraph, coverage shall
  not be required for any experimental or  investigational  drugs  or  any
  drug  which  the  food  and  drug  administration  has  determined to be
  contraindicated for treatment of the specific type of cancer  for  which
  the  drug  has  been  prescribed. The provisions of this paragraph shall
  apply to cancer drugs only and nothing  herein  shall  be  construed  to
  create,  impair,  alter,  limit,  modify,  enlarge, abrogate or prohibit
  reimbursement for drugs used in the treatment of any  other  disease  or
  condition.
    (13)  Consistent  with  federal  law  every insurer delivering a group
  policy or issuing a group  policy  for  delivery  in  this  state  which
  provides coverage supplementing part A and part B of subchapter XVIII of
  the  federal  Social  Security  Act,  42 USC §§ 1395 et seq., shall make
  available and, if requested by the policyholder, provide coverage for at

  least ninety days of care in  a  nursing  home  as  defined  in  section
  twenty-eight  hundred  one  of  the public health law, except where such
  coverage  would  duplicate  coverage  that  is   available   under   the
  aforementioned  subchapter  XVIII. Such coverage shall be made available
  at the inception of all new policies and,  with  respect  to  all  other
  policies at each anniversary date of the policy.
    (A)  Coverage  shall  be subject to a copayment of twenty-five dollars
  per day.
    (B) Brochures  describing  such  coverage  must  be  provided  to  the
  policyholder at the inception of all new policies and thereafter on each
  anniversary  date  of the policy, and with respect to all other policies
  annually at each anniversary date of the policy. Such brochures must  be
  approved  by the superintendent in consultation with the commissioner of
  health.
    (C) The commensurate rate for the coverage must  be  approved  by  the
  superintendent.
    (D)  Such  insurers  shall  report to the superintendent each year the
  number of contract holders  to  whom  such  insurers  have  issued  such
  policies for nursing home coverage and the approximate number of persons
  covered by such policies.
    (14)  (A)  Every  group  or  blanket  policy  delivered  or issued for
  delivery in this state which  provides  hospital,  surgical  or  medical
  coverage   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 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 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.
    (15)(A) Every group or blanket policy delivered or issued for delivery
  in this state which provides major medical or similar comprehensive-type
  coverage  shall  include  coverage  for  prehospital  emergency  medical
  services for the treatment of an emergency condition when such  services
  are  provided  by  an  ambulance service issued a certificate to operate
  pursuant to section three thousand five of the public health law.
    (B) Payment by an insurer pursuant to this section shall be payment in
  full for the services provided. An ambulance service reimbursed pursuant
  to this section shall not charge or seek any reimbursement from, or have
  any recourse against an insured for the services  provided  pursuant  to
  this  paragraph, except for the collection of copayments, coinsurance or
  deductibles for which the insured is responsible for under the terms  of
  the policy.
    (C)   An  insurer  shall  provide  reimbursement  for  those  services
  prescribed by this section at rates negotiated between the  insurer  and
  the  provider  of such services. In the absence of agreed upon rates, an
  insurer shall pay for such services at the usual and  customary  charge,
  which shall not be excessive or unreasonable.
    (D)  The  provisions  of  this  paragraph shall have no application to
  transfers of patients between hospitals or health care facilities by  an
  ambulance service as described in subparagraph (A) of this paragraph.
    (E) As used in this paragraph:
    (i)   "Prehospital   emergency  medical  services"  means  the  prompt
  evaluation 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  pursuant  to this paragraph, reimbursement will 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)  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)  serious  impairment  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.
    (ii) "Emergency condition" means a medical  or  behavioral  condition,
  the  onset  of  which  is  sudden,  that manifests itself by symptoms of
  sufficient severity, including severe pain, 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
  impairment 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.
    (16)  Every  group  or  blanket  policy  which  provides  coverage for
  prescription drugs shall include coverage for the cost of  contraceptive
  drugs or devices approved by the federal food and drug administration or
  generic  equivalents  approved  as  substitutes  by  such  food and drug
  administration under the prescription of a health care provider  legally
  authorized  to  prescribe  under  title  eight of the education law. The
  coverage required by this section shall  be  included  in  policies  and
  certificates only through the addition of a rider.
    (A)   Notwithstanding  any  other  provision  of  this  subsection,  a
  religious employer may request a contract without coverage  for  federal
  food  and  drug  administration  approved contraceptive methods that are
  contrary to the religious employer's religious tenets. If so  requested,
  such  contract  shall  be  provided  without  coverage for contraceptive
  methods.  This paragraph shall not be  construed  to  deny  an  enrollee
  coverage of, and timely access to, contraceptive methods.
    (1)  For  purposes  of  this  subsection, a "religious employer" is an
  entity for which each of the following is true:
    (a) The inculcation of religious values is the purpose of the entity.
    (b) The entity primarily  employs  persons  who  share  the  religious
  tenets of the entity.
    (c) The entity serves primarily persons who share the religious tenets
  of the entity.
    (d)  The  entity  is  a nonprofit organization as described in Section
  6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.
    (2) Every religious employer that invokes the exemption provided under
  this paragraph shall provide written  notice  to  prospective  enrollees
  prior to enrollment with the plan, listing the contraceptive health care
  services the employer refuses to cover for religious reasons.
    (B)  (i)  Where a group policyholder makes an election not to purchase
  coverage  for  contraceptive  drugs  or  devices  in   accordance   with
  subparagraph  (A) of this paragraph each certificateholder covered under
  the policy issued to that group policyholder shall  have  the  right  to
  directly  purchase the rider required by this paragraph from the insurer
  which issued the group policy at the prevailing  small  group  community
  rate  for  such  rider  whether  or  not the employee is part of a small
  group.
    (ii) Where a group policyholder makes  an  election  not  to  purchase
  coverage   for   contraceptive  drugs  or  devices  in  accordance  with

  subparagraph (A) of this  paragraph,  the  insurer  that  provides  such
  coverage   shall  provide  written  notice  to  certificateholders  upon
  enrollment with the insurer of their right to directly purchase a  rider
  for  coverage for the cost of contraceptive drugs or devices. The notice
  shall also advise the certificateholders of the additional  premium  for
  such coverage.
    (C)  Nothing  in  this  paragraph  shall be construed as authorizing a
  group or blanket policy which provides coverage for  prescription  drugs
  to  exclude coverage for prescription drugs prescribed for reasons other
  than contraceptive purposes.
    (D) Such coverage may be subject to reasonable annual deductibles  and
  coinsurance  as  may  be deemed appropriate by the superintendent and as
  are consistent with those established for other drugs or devices covered
  under the policy.
    (17) A group or blanket accident or health insurance policy or issuing
  a group or blanket policy for delivery  in  this  state  which  provides
  coverage  for  hospital,  surgical,  or  medical care coverage shall not
  exclude coverage for  diagnosis  and  treatment  of  medical  conditions
  otherwise  covered  by  the  policy because the treatment is provided to
  diagnose or  treat  autism  spectrum  disorder.  For  purposes  of  this
  section,  "autism  spectrum  disorder" means a neurobiological condition
  that includes autism, Asperger syndrome, Rett's syndrome,  or  pervasive
  developmental disorder.
    (m)  A  group  policy  providing hospital, surgical or medical expense
  insurance for other than accident only shall provide that if all or  any
  portion  of  the  insurance  on  an employee or member insured under the
  policy ceases because of termination of employment or membership in  the
  class  or  classes eligible for coverage under the policy, such employee
  or member shall  be  entitled  without  evidence  of  insurability  upon
  application  to  continue  his  hospital,  surgical  or  medical expense
  insurance for himself or herself and his  or  her  eligible  dependents,
  subject  to all of the group policy's terms and conditions applicable to
  those forms of benefits and to the following conditions:
    (1) Continuation shall cease on the date which the employee, member or
  dependant first becomes, after the date of  election:  (A)  entitled  to
  coverage  under  title  XVIII  of  the United States Social Security Act
  (Medicare) as amended or superseded; or  (B)  covered  as  an  employee,
  member  or dependent by any other insured or uninsured arrangement which
  provides hospital, surgical or medical coverage  for  individuals  in  a
  group which does not contain any exclusion or limitation with respect to
  any pre-existing condition of such employee, member or dependent, except
  the  group  insurance policy conversion option of this section shall not
  be considered as such an arrangement under which an employee, member  or
  dependent could become covered.
    (2) (A) An employee or member who wishes continuation of coverage must
  request  such  continuation  in  writing  within  the  sixty  day period
  following the later of: (i) the date of such termination;  or  (ii)  the
  date  the  employee  is  sent notice by first class mail of the right of
  continuation by the group policyholder.
    (B) An employee or member who wishes continuation  of  coverage  under
  subparagraph  (D)  of paragraph four of this subsection must give notice
  to  the  employer  or  group  policyholder  within  sixty  days  of  the
  determination  under  title  II or title XVI of the United States Social
  Security Act that such employee or member was disabled at  the  time  of
  termination  of employment or membership or at any time during the first
  sixty days of continuation of coverage.
    (3) An employee or member electing continuation must pay to the  group
  policyholder  or his employer, but not more frequently than on a monthly

  basis in advance, the amount of the required premium  payment,  but  not
  more  than  one  hundred  two percent of the group rate for the benefits
  being continued under the group policy on the due date of each  payment.
  The  employee's  or  member's written election of continuation, together
  with the first premium payment required to establish premium payment  on
  a  monthly  basis  in  advance,  must  be  given  to the policyholder or
  employer within sixty days  of  the  date  the  employee's  or  member's
  benefits would otherwise terminate.
    (4)  Subject  to  paragraph  one  of  this subsection, continuation of
  benefits under the group policy for any person shall  terminate  at  the
  first to occur of the following:
    (A)  The  date  thirty-six  months  after  the  date the employee's or
  member's benefits under  the  policy  would  otherwise  have  terminated
  because of termination of employment or membership; or
    (B) The end of the period for which premium payments were made, if the
  employee  or  member  fails to make timely payment of a required premium
  payment; or
    (C) In the case of an eligible dependent of an employee or member, the
  date thirty-six months after the date such person's benefits  under  the
  policy would otherwise have terminated by reason of:
    (i) the death of the employee or member;
    (ii)  the  divorce  or legal separation of the employee or member from
  his or her spouse;
    (iii) the employee or member becoming entitled to benefits under title
  XVIII of the United States Social Security Act (Medicare); or
    (iv) a dependent child ceasing to  be  a  dependent  child  under  the
  generally applicable requirements of the policy; or
    (D)  The  date on which the group policy is terminated or, in the case
  of an employee, the date his employer terminates participation under the
  group policy. However, if this clause applies and the  coverage  ceasing
  by  reason  of  such  termination  is replaced by similar coverage under
  another group policy, the following shall apply:
    (i) The employee or member shall have  the  right  to  become  covered
  under  that  other  group  policy, for the balance of the period that he
  would have remained covered under the prior group policy  in  accordance
  with  this subparagraph had a termination described in this subparagraph
  not occurred, and
    (ii) The minimum level of benefits to be provided by the  other  group
  policy  shall  be  the  applicable  level of benefits of the prior group
  policy reduced by any benefits payable under that  prior  group  policy,
  and
    (iii) The prior group policy shall continue to provide benefits to the
  extent  of  its  accrued liabilities and extension of benefits as if the
  replacement had not occurred.
    (5) A notification of the continuation privilege and the  time  period
  in  which  to request continuation shall be included in each certificate
  of coverage.
    (6) This subsection shall  not  be  applicable  where  a  continuation
  benefit is available to the employee or member pursuant to Chapter 18 of
  the  Employee Retirement Income Security Act, 29 U.S.C. § 1161 et seq or
  Chapter 6A of the Public Health Service Act, 42 U.S.C. § 300 bb -  1  et
  seq.  However,  a  group policy shall offer an insured who has exhausted
  continuation coverage pursuant to Chapter 18 of the Employee  Retirement
  Income  Security  Act,  29  U.S.C.  §  1161 et seq. or Chapter 6A of the
  Public Health Service  Act,  42  U.S.C.  §  300  bb  -  1  et  seq.  the
  opportunity  to  continue  coverage for up to thirty-six months from the
  date the employee's or member's  continuation  coverage  began,  if  the

  employee  or  member  is  entitled  to  less  than  thirty-six months of
  continuation benefits under federal law.
    (7)(A)  Special  enrollment period. An individual who does not have an
  election of continuation coverage as described  in  this  subsection  in
  effect  on  the effective date of the American Recovery and Reinvestment
  act of 2009, but who would be an assistance  eligible  individual  under
  Title  III  of  such  act  if  such  election  were in effect, may elect
  continuation coverage pursuant to this subsection. Such  election  shall
  be made no later than sixty days after the date the administrator of the
  group  health  plan  (or  other  entity  involved)  provides  the notice
  required by section 3001(a)(7) of the American Recovery and Reinvestment
  act of 2009. The administrator of the group health plan (or other entity
  involved) shall provide such individuals with additional notice  of  the
  right  to elect coverage pursuant to this paragraph within sixty days of
  the date of enactment of the American Recovery and Reinvestment  act  of
  2009.
    (B) Continuation coverage elected pursuant to subparagraph (A) of this
  paragraph  shall commence with the first period of coverage beginning on
  or after the  date  of  the  enactment  of  the  American  Recovery  and
  Reinvestment  act  of  2009  and  shall  not extend beyond the period of
  continuation coverage that would have been required if the coverage  had
  instead been elected pursuant to paragraph two of this subsection.
    (C)  With  respect  to  an individual who elects continuation coverage
  pursuant to subparagraph (A) of this paragraph, the period beginning  on
  the  date  of  the  qualifying event and ending on the date of the first
  period of coverage on or after the enactment of  the  American  Recovery
  and  Reinvestment  act  of  2009  shall  be  disregarded for purposes of
  determining the sixty-three day period  referred  to  in  section  three
  thousand two hundred thirty-two of this article.
    (n)  In  addition  to  all  the  rights of conversion and continuation
  otherwise provided for herein, employees or members  insured  under  the
  policy  who  are also members of a reserve component of the armed forces
  of the United States, including the National Guard, shall be entitled to
  have  supplementary  conversion  and  continuation  rights  in   certain
  circumstances as follows:
    (1)  If  the  employee  or  member  insured enters upon active duty as
  defined in subsection (o) of this section, and  the  employer  or  group
  policyholder does not voluntarily maintain coverage for such employee or
  member insured, the employee or member insured shall be entitled to have
  his  or her coverage continued under the group policy in accordance with
  the conditions and limitations contained  in  paragraph  seven  of  this
  subsection  and  have issued at the end of the period of continuation an
  individual conversion policy subject to the terms  of  this  subsection.
  The  effective date for the conversion policy shall be the day following
  the termination of insurance under the group policy, or if  there  is  a
  continuation  of  coverage on the day following the end of the period of
  continuation.
    (2) If  the  employer  or  group  policyholder  does  not  voluntarily
  maintain  coverage  for the employee or member insured during the period
  of active duty, and such employee or member insured does not  elect  the
  supplementary  conversion  and  continuation rights provided for herein,
  coverage for such employee or member insured shall be  suspended  during
  the period of active duty.
    (3)  If  the  employee  or  member  insured  elects  the supplementary
  continuation right provided for herein or coverage under the group  plan
  is suspended, and such employee or member insured dies during the period
  of  active  duty, the conversion right provided by this section shall be
  available to the surviving spouse and children, and shall  be  available

  to  a  child  solely  with respect to himself or herself upon his or her
  attaining the limiting age of coverage  under  the  group  policy  while
  covered  as  a dependent thereunder. It shall also be available upon the
  divorce  or annulment of the marriage of the employee or member insured,
  to the former spouse of such employee or member insured, if such divorce
  or annulment occurs during the period of active duty.
    (4) If  the  employee  or  member  insured  elects  the  supplementary
  conversion  and continuation right provided for herein or coverage under
  the group plan is suspended, and such  employee  or  member  insured  is
  either  reemployed or restored to participation in the group upon return
  to civilian status, he or she shall be entitled to resume  participation
  in  insurance  offered  by  the  group pursuant to this section, with no
  limitations or conditions imposed as a result of such period  of  active
  duty  except as set forth in subparagraphs (A) and (B) herein. The right
  of resumption provided for herein  shall  extend  to  coverage  for  the
  spouse  and dependents of the employee or member insured and shall be in
  addition to other existing rights granted pursuant to state and  federal
  laws  and  regulations  and shall not be deemed to qualify or limit such
  rights in any way. No exclusion or waiting  period  may  be  imposed  in
  connection  with  coverage of a health or physical condition of a person
  entitled to such right of resumption, or a health or physical  condition
  of any other person who is covered by the policy unless:
    (A)  the  condition  arose  during  the  period of active duty and the
  condition has been determined by the secretary of veterans affairs to be
  a condition incurred in the line of duty; or
    (B) a waiting period was imposed and had not been completed  prior  to
  the  period  of  suspension;  in no event, however, shall the sum of the
  waiting periods imposed  prior  to  and  subsequent  to  the  period  of
  suspension exceed the length of the waiting period originally imposed.
    (5)  If  the  employee  or  member  insured  elects  the supplementary
  conversion and continuation coverage provided for herein:
    (A) when such employee or  member  insured  is  either  reemployed  or
  restored to participation in the group, coverage under the supplementary
  rights  provided for herein shall terminate on the date that coverage is
  effective due to resumption of participation in the group.
    (B) when such employee or member insured is not reemployed or restored
  to participation in the group upon return to civilian status, he or  she
  shall  be entitled to the conversion and continuation rights provided by
  subsections (e) and (m) of this section.
    (i) To elect an individual conversion policy  pursuant  to  subsection
  (e)  of  this  section, the employee or member insured must apply to the
  insurer within thirty-one days of the  termination  of  active  duty  or
  discharge  from  hospitalization  incident  to  such  active duty, which
  hospitalization continues for a period of not more than one  year.  Upon
  commencement of coverage under the conversion right provided pursuant to
  subsection  (e)  of  this  section,  coverage  under  the  supplementary
  continuation right provided for herein shall terminate.
    (ii) To elect continuation of coverage pursuant to subsections (e) and
  (m) of this section, the employee or member insured  must  request  such
  continuation  of  the employer within thirty-one days of the termination
  of active duty or discharge from hospitalization incident to such active
  duty, which hospitalization continues for a period of not more than  one
  year.  Upon  commencement  of  coverage  under  the  continuation  right
  provided pursuant to subsection (e) of this section, coverage under  the
  supplementary  continuation  right  provided for herein shall terminate.
  The employee or member insured shall be entitled to have issued  at  the
  end of the period of continuation an individual conversion policy.

    (6) If coverage under the group plan is suspended during the period of
  active duty:
    (A)  when  the  employee or member insured returns to participation in
  the group plan, coverage under the group plan shall  be  retroactive  to
  the date of termination of the period of active duty.
    (B) when such employee or member insured is not reemployed or restored
  to  participation in the group upon return to civilian status, he or she
  shall be entitled to the conversion and continuation rights provided  by
  subsections (e) and (m) of this section.
    (i)  To  elect  an individual conversion policy pursuant to subsection
  (e) of this section, the employee or member insured must  apply  to  the
  insurer  within  thirty-one  days  of  the termination of active duty or
  discharge from hospitalization  incident  to  such  active  duty,  which
  hospitalization continues for a period of not more than one year.
    (ii) To elect continuation of coverage pursuant to subsections (e) and
  (m)  of  this  section, the employee or member insured must request such
  continuation of the employer within thirty-one days of  the  termination
  of active duty or discharge from hospitalization incident to such active
  duty,  which hospitalization continues for a period of not more than one
  year. The employee or member insured shall be entitled to have issued at
  the end of the period of continuation an individual conversion policy.
    (7) A group policy providing hospital,  surgical  or  medical  expense
  insurance  for other than accident only shall provide that if all or any
  portion of the insurance on an employee  or  member  insured  under  the
  policy  ceases  because  the  employee  or  member insured is ordered to
  active duty as defined in subsection (o) of this section, such  employee
  or  member  insured shall be entitled, without evidence of insurability,
  upon application to continue his or her hospital,  surgical  or  medical
  expense  insurance  for  himself  or  herself  and  his  or her eligible
  dependents, under the supplementary conversion and  continuation  rights
  provided  for  herein,  subject  to  all of the group policy's terms and
  conditions applicable to those forms of benefits and  to  the  following
  conditions:
    (A)  continuation  shall  not  be available for: (i) any person who is
  covered, becomes covered or could be  covered  by  title  XVIII  of  the
  United States Social Security Act (Medicare) as amended or superseded or
  (ii) an employee, member or dependent who is covered, becomes covered or
  could  become  covered  as an employee, member or dependent by any other
  insured or uninsured arrangement which provides  hospital,  surgical  or
  medical  coverage  for  individuals in a group, except that the coverage
  available to active duty members of the  uniformed  services  and  their
  family  members  shall not be considered a group under the terms of this
  subsection, and except that the group insurance policy conversion option
  of this section shall not be considered as  such  an  arrangement  under
  which an employee, member or dependent could become covered.
    (B)  an employee or member insured who wishes continuation of coverage
  pursuant to this subsection must request such  continuation  in  writing
  within sixty days of being ordered to active duty.
    (C)  an  employee  or member insured electing continuation pursuant to
  this subsection must pay  to  the  group  policyholder  or  his  or  her
  employer,  but  not  more frequently than on a monthly basis in advance,
  the amount of the required premium payment, but not more than the  group
  rate  for the benefits being continued under the group policy on the due
  date of each payment.
    (8) The supplementary conversion and continuation rights provided  for
  herein shall apply to:

    (A)  policies  not  covered  by  Chapter 18 of the Employee Retirement
  Income Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of  the
  Public Health Service Act, 42 U.S.C. section 300bb-1 et seq;
    (B)  policies  covered by Chapter 18 of the Employee Retirement Income
  Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the  Public
  Health  Service  Act, 42 U.S.C. section 300bb-1 et seq, when active duty
  for reservists and the refusal of an employer  to  voluntarily  maintain
  coverage  for  such period of active duty is not considered a qualifying
  event.
    (o) To be entitled to the right defined  in  subsection  (n)  of  this
  section  a  person  must be a member of a reserve component of the armed
  forces of the United States, including the National Guard, who either:
    (A) voluntarily or involuntarily enters upon active duty  (other  than
  for  the  purpose  of  determining his or her physical fitness and other
  than for training), or
    (B) has his or her active duty voluntarily or  involuntarily  extended
  during  a  period when the president is authorized to order units of the
  ready reserve or members of a reserve component to active duty, provided
  that such  additional  active  duty  is  at  the  request  and  for  the
  convenience of the federal government, and
    (C) serves no more than four years of active duty.
    (p)(1)  Except  as provided in this section, if an insurer delivers or
  issues for delivery in this  state  a  group  or  blanket  policy  which
  provides  hospital,  surgical or medical expense coverage for other than
  accident only, the insurer must renew or continue in force such coverage
  at the option of the policyholder.
    (2) An insurer may nonrenew or discontinue coverage under such a group
  or blanket policy based only on one or more of the following:
    (A) The policyholder or a  participating  entity  has  failed  to  pay
  premiums  or contributions in accordance with the terms of the policy or
  the insurer has not received timely premium payments.
    (B) The policyholder or a participating entity has performed an act or
  practice that constitutes fraud or made an intentional misrepresentation
  of material fact under the terms of the coverage.
    (C) The policyholder  has  failed  to  comply  with  a  material  plan
  provision  relating  to  employer  contribution  or  group participation
  rules, as permitted under section four thousand two hundred  thirty-five
  of this chapter.
    (D)  The  insurer  is  ceasing to offer group or blanket policies in a
  market in accordance with paragraph three of this subsection.
    (E) The policyholder ceases to meet the requirements for a group under
  section four thousand two hundred  thirty-five  of  this  chapter  or  a
  participating  employer, labor union, association or other entity ceases
  membership or participation in the group to which the policy is  issued.
  Coverage  terminated  pursuant to this paragraph shall be done uniformly
  without regard to any  health  status-related  factor  relating  to  any
  covered individual.
    (F) In the case of an insurer that offers a group or blanket policy in
  a  market  through  a  network  plan, there is no longer any enrollee in
  connection with such plan who lives, resides, or works  in  the  service
  area  of the insurer (or in the area for which the insurer is authorized
  to do business).
    (G) Such other reasons as are acceptable  to  the  superintendent  and
  authorized by the Health Insurance Portability and Accountability Act of
  1996,  Public  Law  104-191,  and  any  later  amendments  or  successor
  provisions, or by any federal regulations or rules  that  implement  the
  provisions of the Act.

    (3)(A) In any case in which an insurer decides to discontinue offering
  a  particular  class of group or blanket policy of hospital, surgical or
  medical expense insurance offered in the small or  large  group  market,
  the  policy  of  such  class  may  be  discontinued  by  the  insurer in
  accordance with this chapter in such market only if:
    (i)  the insurer provides written notice to each policyholder provided
  coverage of this class in such  market  (and  to  all  participants  and
  beneficiaries  covered  under  such  coverage) of such discontinuance at
  least ninety days prior to the date of discontinuance of such coverage;
    (ii) the insurer offers to each policyholder provided coverage of this
  class in such market, the option to purchase all (or, in the case of the
  large group market, any) other hospital, surgical  and  medical  expense
  coverage  currently  being  offered  by  the  insurer to a group in such
  market; and
    (iii) in exercising the option to discontinue coverage of  this  class
  and  in  offering  the  option  of  coverage  under  item  (ii)  of this
  subparagraph, the insurer acts uniformly without regard  to  the  claims
  experience  of  those  policyholders or any health status-related factor
  relating to any insureds covered or new insureds who may become eligible
  for such coverage.
    (B) In any case in which an insurer elects to discontinue offering all
  hospital, surgical and medical  expense  coverage  in  the  small  group
  market or the large group market, or both markets, in this state, health
  insurance coverage may be discontinued by the insurer only if:
    (i)  the  insurer provides written notice to the superintendent and to
  each policyholder (and participants and beneficiaries covered under such
  coverage) of such discontinuance at least one hundred eighty days  prior
  to the date of the discontinuance of such coverage;
    (ii)  all  hospital,  surgical  and medical expense coverage issued or
  delivered for issuance in this state in  such  market  (or  markets)  is
  discontinued  and  coverage  under  such  policies  in  such  market (or
  markets) is not renewed; and
    (iii) in addition to the notice to the superintendent referred  to  in
  item   (i)   of   this   subparagraph,  the  insurer  must  provide  the
  superintendent with a written plan to minimize potential  disruption  in
  the marketplace occasioned by its withdrawal from the market.
    (C)  In  the  case  of a discontinuance under subparagraph (B) of this
  paragraph in a market, the insurer may not provide for the  issuance  of
  any  group  or  blanket  policy of hospital, surgical or medical expense
  insurance in that market in this  state  during  the  five  year  period
  beginning on the date of the discontinuance of the last health insurance
  policy not so renewed.
    (4)  At the time of coverage renewal, an insurer may modify the health
  insurance coverage for a group or blanket policy offered to a  large  or
  small group policyholder so long as such modification is consistent with
  this  chapter  and  effective  on  a uniform basis among all small group
  policyholders with that policy form.
    (5) For purposes of this subsection the term "network plan" shall mean
  a health insurance policy under which  the  financing  and  delivery  of
  health  care  (including  items  and services paid for as such care) are
  provided, in whole or in part, through a defined set of providers  under
  contract  either with the insurer or another entity which has contracted
  with the insurer.
    (q)(1) No insurer delivering or issuing for delivery in this  state  a
  group  or  blanket  policy  which provides hospital, surgical or medical
  expense  coverage  shall  establish  rules  for  eligibility  (including
  continued  eligibility) of any individual or dependent of the individual

  to enroll under  the  policy  based  on  any  of  the  following  health
  status-related factors:
    (A) Health status.
    (B) Medical condition (including both physical and mental illnesses).
    (C) Claims experience.
    (D) Receipt of health care.
    (E) Medical history.
    (F) Genetic information.
    (G) Evidence of insurability (including conditions arising out of acts
  of domestic violence).
    (H) Disability.
    (2)  For  purposes  of  paragraph  one  of  this subsection, rules for
  eligibility include rules defining any applicable  waiting  periods  for
  such enrollment.
    (3)  No  insurer may, on the basis of any health status-related factor
  in relation to the insured or dependent  of  the  insured,  require  any
  insured  (as a condition of enrollment or continued enrollment under the
  policy) to pay a premium or contribution  which  is  greater  than  such
  premium for a similarly situated insured enrolled in the plan.
    (4)  Nothing  in  this  subsection shall require an insurer to issue a
  group or blanket policy to a group comprised of fifty-one or more  lives
  exclusive of spouses and dependents.
    (5)  Where  an  eligible  insured  or  dependent of an insured rejects
  initial enrollment in a group or blanket policy that provides  hospital,
  surgical  or  medical  expense  insurance,  an  insurer  shall permit an
  insured or dependent of an insured to  enroll  for  coverage  under  the
  terms of the policy if each of the following conditions is met:
    (A)  The insured or dependent was covered under another plan or policy
  at the time coverage was initially offered.
    (B)(i) Coverage under  the  other  plan  or  policy  was  provided  in
  accordance  with  continuation  required by federal or state law and was
  exhausted; or
    (ii)  Coverage  under  the  other  plan  or  policy  was  subsequently
  terminated  as  a  result  of loss of eligibility for one or more of the
  following reasons:
    (I) termination of employment;
    (II) termination of the other plan or policy;
    (III) death of the spouse;
    (IV) legal separation, divorce, or annulment;
    (V) reduction in the number of hours of employment; or
    (iii) Policyholder contributions toward the payment of premium for the
  other plan or contract were terminated.
    (C) Coverage must be applied for within thirty days of termination for
  one of the reasons set forth in subparagraph (B) of this paragraph.
    (6) With respect to group or blanket policies delivered or issued  for
  delivery  in  this  state  covering  between  two and fifty employees or
  members, the provisions of this subsection shall in no way diminish  the
  rights  of  such  groups  pursuant to section three thousand two hundred
  thirty-one of this article.
    (r)(1)  As  used  in  this  subsection,  "dependent  child"  means  an
  unmarried child through age twenty-nine of an employee or member insured
  under  a  group  policy,  regardless of financial dependence, who is not
  insured by or eligible for coverage under any  employee  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 for
  other  than  specific  diseases  or  accidents  only, and which provides
  dependent coverage that terminates  at  a  specified  age,  shall,  upon
  application  of the employee, member or dependent child, as set forth in
  subparagraphs (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 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
  policy;
    (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)  of  this
  paragraph.  Any  premium received within the thirty-day period after the
  due date shall be considered timely;
    (E) 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)  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) 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) of this paragraph; or
    (iii)  the  date  on  which  the  group  policy  is terminated and not
  replaced by coverage under another group policy; and
    (H) 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;
    (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
  subparagraph (C) of this paragraph.
    (3)(A)  Insurers  shall submit such reports as may be requested by the
  superintendent to evaluate the effectiveness  of  coverage  pursuant  to
  this  subsection  including,  but  not  limited to, quarterly enrollment
  reports.
    (B) The  superintendent  may  promulgate  regulations  to  ensure  the
  orderly  implementation  and  operation  of  the  continuation  coverage
  provided  pursuant  to   this   subsection,   including   premium   rate
  adjustments.