Section 4303. Benefits

(a)  Every  contract issued by a hospital service
  corporation or health service corporation which  provides  coverage  for
  in-patient hospital care shall also provide coverage:
    (1) For preadmission testing performed in hospital facilities prior to
  scheduled  surgery.  A  patient who uses the out-patient facilities of a
  hospital shall be entitled to benefits for tests ordered by a  physician
  which are performed as a planned preliminary to admission of the patient
  as an in-patient for surgery in the same hospital, provided that:
    (A)  tests  are  necessary  for  and consistent with the diagnosis and
  treatment of the condition for which surgery is to be performed,
    (B) reservations for a hospital bed and for an  operating  room  shall
  have been made prior to the performance of the tests,
    (C) surgery actually takes place within seven days of such presurgical
  tests, and
    (D) the patient is physically present at the hospital for the tests.
    (2)   For  services  to  treat  an  emergency  condition  in  hospital
  facilities.  For the purpose of this  provision,  "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 (A) placing  the  health  of  the  person
  afflicted  with  such condition in serious jeopardy, or in the case of a
  behavioral condition placing the health of  such  person  or  others  in
  serious  jeopardy,  or  (B)  serious  impairment to such person's bodily
  functions; (C) serious dysfunction of any bodily organ or part  of  such
  person; or (D) serious disfigurement of such person.
    (3)  For home care to residents in this state. Such home care coverage
  shall be included at the  inception  of  all  new  contracts  and,  with
  respect  to  all  other  contracts, added at any anniversary date of the
  contract subject to evidence  of  insurability.  Such  coverage  may  be
  subject  to an annual deductible of not more than fifty dollars for each
  covered person and may be  subject  to  a  coinsurance  provision  which
  provides  for  coverage  of  not  less  than seventy-five percent of the
  reasonable cost of services for which  payment  may  be  made.  No  such
  corporation need provide such coverage to persons eligible for medicare.
    (A)  Home  care  shall mean the care and treatment of a covered person
  who is under the care of a physician but only if:
    (i) hospitalization or confinement in a nursing facility as defined in
  subchapter XVIII of the Social Security Act, 42 U.S.C. §  1395  et  seq,
  would otherwise have been required if home care was not provided, and
    (ii)  the  plan  covering  the  home health service is established and
  approved in writing by such physician.
    (B) 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.
    (C) Home care 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, and
    (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  or provided under the contract if the
  covered person had been hospitalized or confined in  a  skilled  nursing

  facility  as  defined in subchapter XVIII of the Social Security Act, 42
  U.S.C. § 1395 et seq.
    (D)  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 covered person. Four  hours  of  home  health
  aide  service shall be considered as one home care visit. Every contract
  issued by a hospital service corporation or health  service  corporation
  which  provides  coverage  supplementing part A and part B of subchapter
  XVIII of the Social Security Act, 42 U.S.C. § 1395  et  seq,  must  make
  available  and,  if  requested  by a subscriber holding a direct payment
  contract or by all subscribers in a group remittance  group  or  by  the
  contract  holder  in  the  case  of  group  contracts issued pursuant to
  section four thousand  three  hundred  five  of  this  article,  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 contract 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 group remitting agent or group contract holder
  prior to inception of such contract 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.
    The provisions of this subsection shall not apply to a contract issued
  pursuant  to  section  four  thousand three hundred five of this article
  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) Every contract issued by a medical expense  indemnity  corporation
  or  a  health service corporation 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 contract issued pursuant to section  four  thousand
  three hundred five of this article 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.
    (c)  (1)  (A)  Every  contract  issued by a corporation subject to the
  provisions of this article  which  provides  hospital  service,  medical
  expense  indemnity  or  both  shall  provide coverage for maternity care
  including hospital, surgical or medical care to  the  same  extent  that
  hospital  service,  medical  expense  indemnity or both are provided for
  illness or disease under the contract.  Such  maternity  care  coverage,
  other than coverage for perinatal complications, shall include inpatient
  hospital  coverage  for  mother and for newborn for at least forty-eight
  hours after childbirth for any delivery other than a caesarean  section,
  and  for  at  least ninety-six hours following 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.
    (B)  Maternity  care  coverage  also shall include, at minimum, parent
  education, assistance and training in breast or bottle feeding, and  the
  performance of any necessary maternal and newborn clinical assessments.
    (C) The mother shall have the option to be discharged earlier than the
  time  periods established in subparagraph (A) of this paragraph. 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  contract.  The  contract
  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
  contract  and  subject  to  the  provisions  of  this paragraph, and not
  subject to deductibles, coinsurance or copayments.
    (2) Coverage provided under this subsection  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.
    (d) (1) A hospital service corporation or a health service corporation
  which provides coverage for in-patient hospital care must make available
  and,  if  requested  by  a  person  holding  a direct payment individual
  contract or by all persons holding individual contracts in a group whose
  premiums are paid by a remitting agent or by the contract holder in  the
  case  of a group contract issued pursuant to section four thousand three
  hundred five of this article,  provide  coverage  for  care  in  nursing
  homes. Such coverage shall be made available at the inception of all new
  contracts  and,  with respect to all other contracts, at any anniversary
  date  subject  to  evidence  of  insurability.  Written  notice  of  the
  availability  of such coverage shall be delivered to the group remitting
  agent or group contract holder prior to inception of such  contract  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) For the purpose of this subsection, care in  nursing  homes  shall
  mean  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 two thousand 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.  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. The level of benefits
  to be provided for nursing home care must be reasonably related  to  the
  benefits provided for hospital care.
    (e) (1) A hospital service corporation or a health service corporation
  which provides coverage for in-patient hospital care must make available
  and,  if  requested  by  a  person  holding  a direct payment individual
  contract or by all persons holding individual contracts in a group whose
  premiums are paid by a remitting agent or by the contract holder in  the

  case  of a group contract issued pursuant to section four thousand three
  hundred five of this article, provide coverage for  ambulatory  care  in
  hospital out-patient facilities, as a hospital is defined in section two
  thousand eight hundred one of the public health law, or subchapter XVIII
  of  the  Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of
  the availability of such  coverage  shall  be  delivered  to  the  group
  remitting  agent  or  group  contract  holder prior to inception of such
  contract 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) For the purpose of this subsection, ambulatory  care  in  hospital
  out-patient  facilities  shall  mean  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 (i) related to and necessary  for
  the  treatment  or  diagnosis  of  the patient's illness or injury, (ii)
  ordered by a physician and  (iii)  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. Such coverage shall be made available at the inception of  all
  new  contracts  and,  with  respect  to  all  other  contracts,  at  any
  anniversary date subject to evidence of insurability.
    (f) (1) A medical expense indemnity corporation or  a  health  service
  corporation  which  provides coverage for physicians' services must make
  available and, if requested by a person  holding  an  individual  direct
  payment  contract  or  by  all persons holding individual contracts in a
  group whose premiums are paid by a remitting agent or  by  the  contract
  holder  in  the case of a group contract issued pursuant to section four
  thousand three hundred  five  of  this  article,  provide  coverage  for
  ambulatory   care   in   physicians'  offices.  Written  notice  of  the
  availability of such coverage shall be delivered to the group  remitting
  agent  or  group contract holder prior to inception of such contract 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) For the purpose of this subsection, ambulatory care in physicians'
  offices  shall  mean  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 (i) related to and
  necessary for the treatment or diagnosis of  the  patient's  illness  or
  injury,  and  (ii)  ordered  by a physician. Such coverage shall be made
  available at the inception of all new contracts and, with respect to all
  other  contracts  at  any  anniversary  date  subject  to  evidence   of
  insurability.
    (g)   (1)   A   hospital  service  corporation  or  a  health  service
  corporation, which provides group, group remittance  or  school  blanket
  coverage  for  inpatient  hospital  care,  shall  provide as part of its
  contract broad-based coverage for the diagnosis and treatment of mental,
  nervous or emotional disorders or  ailments,  however  defined  in  such

  contract,  at  least  equal  to  the  coverage provided for other health
  conditions and shall include:
    (A)  benefits  for  in-patient  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.
    (B)  benefits  for  out-patient  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.
    (C) Such coverage 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 contract. 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 contract.
    (D) For the purpose  of  this  subsection,  "active  treatment"  means
  treatment  furnished  in  conjunction  with  in-patient  confinement for
  mental, nervous or  emotional  disorders  or  ailments  that  meet  such
  standards  as  shall  be  prescribed  pursuant to the regulations of the
  commissioner of mental health.
    (E) In the event the group remittance  group  or  contract  holder  is
  provided  coverage  under  this  subsection  and  under paragraph one of
  subsection (h) of this section from the same health service corporation,
  or under a contract that is jointly underwritten by two  health  service
  corporations  or  by  a health service corporation and a medical expense
  indemnity corporation, the aggregate of the benefits for outpatient care
  obtained under subparagraph (B) of this paragraph and paragraph  one  of
  subsection  (h)  of  this section may be limited to not less than twenty
  visits in any contract year, plan year or calendar year.
    (2)  (A)  A  hospital  service  corporation  or   a   health   service
  corporation,  which  provides  group, group remittance or school blanket
  coverage for inpatient hospital care, shall provide comparable  coverage
  for  adults  and  children  with biologically based mental illness. Such
  hospital service corporation or health service  corporation  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 contract, including network
  limitations or variations, exclusions, co-pays, coinsurance, deductibles
  or other specific cost sharing mechanisms.  Provided  further,  where  a
  contract  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
  contract is written under one license or two licenses.
    (B) For purposes of this  subsection,  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, anorexia, and bulimia.
    (3) For purposes of this subsection, 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:
    (A)    serious    suicidal    symptoms   or   other   life-threatening
  self-destructive behaviors;
    (B) significant psychotic symptoms (hallucinations, delusion,  bizarre
  behaviors);
    (C) behavior caused by emotional disturbances that placed the child at
  risk of causing personal injury or significant property damage; or
    (D) behavior caused by emotional disturbances that placed the child at
  substantial risk of removal from the household.
    (4)  (A)  The provisions of paragraph two of this subsection shall not
  apply to any group remittance group or group contract holder with  fifty
  or  fewer  employees  who  is a group remittance group or group contract
  holder of a policy that is subject to the provisions  of  this  section;
  provided  however  that a hospital service corporation or health service
  corporation  must  make  available,  and  if  requested  by  such  group
  remitting  agent  or  group  contract  holder,  provide  the coverage as
  specified in paragraph two of this subsection.  Written  notice  of  the
  availability  of such coverage shall be delivered to the remitting agent
  or group contract  holder  prior  to  inception  of  such  contract  and
  annually thereafter.
    (B)  The  superintendent  shall develop and implement a methodology to
  fully cover the cost to any such group contract holder for providing the
  coverage required in paragraph one of this subsection. Such  methodology
  shall  be  financed from moneys from the General Fund that shall be made
  available to the superintendent for such purpose.
    (5)(A) Nothing in this subsection 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.
    (B)  Nothing  in  this  subsection  shall  be  construed  to prevent a
  contract from providing services  through  a  network  of  participating
  providers   who  shall  meet  certain  requirements  for  participation,
  including provider credentialing.
    (C) Nothing in  this  subsection  shall  be  construed  to  require  a
  contract:    (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.
    (D) Nothing in this subsection shall be deemed to require  a  contract
  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.
    (h)  (1)  A  medical expense indemnity corporation or a health service
  corporation, which provides group, group remittance  or  school  blanket
  coverage  for  physician services, shall provide as part of its contract
  broad-based coverage for the diagnosis and treatment of mental,  nervous
  or emotional disorders or ailments, however defined in such contract, at
  least  equal  to  the  coverage provided for other health conditions and
  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  subsection  (n)  of  this
  section,  or  a  professional corporation or university faculty practice
  corporation thereof, which benefits may be  limited  to  not  less  than
  twenty  visits  in  any  contract year, plan year or calendar year. Such

  coverage 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  contract.  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 contract. In the event the group remittance group or
  contract holder is provided coverage provided under this  paragraph  and
  under  subparagraph  (B)  of  paragraph  one  of  subsection (g) of this
  section from the same health service corporation, or  under  a  contract
  which is jointly underwritten by two health service corporations or by a
  health  service corporation and a medical expense indemnity corporation,
  the aggregate of  the  benefits  for  out-patient  care  obtained  under
  subparagraph  (B) of paragraph one of subsection (g) of this section and
  this paragraph may be limited to not less  than  twenty  visits  in  any
  contract year, plan year or calendar year.
    (2)  (A)  A  medical expense indemnity corporation or a health service
  corporation, which provides group, group remittance  or  school  blanket
  coverage  for  physician services, shall provide comparable coverage for
  adults and children with biologically based mental illness. Such medical
  expense indemnity corporation or health service corporation  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 contract, including network
  limitations or variations, exclusions, co-pays, coinsurance, deductibles
  or other specific cost sharing mechanisms.  Provided  further,  where  a
  contract  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
  contract is written under one license or two licenses.
    (B) For purposes of this  subsection,  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 disorder, anorexia, and bulimia.
    (3) For purposes of this subsection, 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:
    (A)   serious   suicidal   symptoms    or    other    life-threatening
  self-destructive behaviors;
    (B)  significant psychotic symptoms (hallucinations, delusion, bizarre
  behaviors);
    (C) behavior caused by emotional disturbances that placed the child at
  risk of causing personal injury or significant property damage; or
    (D) behavior caused by emotional disturbances that placed the child at
  substantial risk of removal from the household.
    (4) (A) The provisions of paragraph two of this subsection  shall  not
  apply  to any group remittance group or group contract holder with fifty
  or fewer employees who is a group remittance  group  or  group  contract
  holder  of a contract that is subject to the provisions of this section;
  provided, however, that a hospital service corporation or health service
  corporation  must  make  available,  and  if  requested  by  such  group
  remitting  agent  or  group  contract  holder,  provide  the coverage as
  specified in paragraph two of this subsection.  Written  notice  of  the

  availability  of  the coverage shall be delivered to the group remitting
  agent or group contract holder prior to inception of such  contract  and
  annually thereafter.
    (B)  The  superintendent  shall develop and implement a methodology to
  fully cover the cost to  any  such  group  remittance  group  and  group
  contract  holder for providing the coverage required in paragraph one of
  this subsection. Such methodology shall be financed from moneys from the
  General Fund that shall be made available to the superintendent for such
  purpose.
    (5)(A) Nothing in this subsection 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.
    (B)  Nothing  in  this  subsection  shall  be  construed  to prevent a
  contract from providing services  through  a  network  of  participating
  providers   who  shall  meet  certain  requirements  for  participation,
  including provider credentialing.
    (C) Nothing in  this  subsection  shall  be  construed  to  require  a
  contract:    (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.
    (D) Nothing in this subsection shall be deemed to require  a  contract
  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.
    (i)   A  medical  expense  indemnity  corporation  or  health  service
  corporation which provides coverage  for  physicians,  psychiatrists  or
  psychologists  for  psychiatric  or  psychological  services  or for the
  diagnosis and treatment of mental, nervous or  emotional  disorders  and
  ailments,  however  defined in such contract, must make available and if
  requested by all persons holding individual contracts in a  group  whose
  premiums  are paid by a remitting agent or by the contract holder in the
  case of a group contract issued pursuant to section four thousand  three
  hundred  five  of  this  article,  provide  the  same  coverage 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. The state board for  social
  work  shall  maintain  a  list  of  all licensed clinical social workers
  qualified for reimbursement under this subsection. Such  coverage  shall
  be  made  available  at  the  inception  of  all new contracts and, with
  respect to all other contracts,  at  any  anniversary  date  subject  to
  evidence  of  insurability.  Written  notice of the availability of such
  coverage shall be delivered  to  the  group  remitting  agent  or  group
  contract  holder  prior  to  inception  of  such  contract  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.
    (j)(1) A health  service  corporation  or  medical  expense  indemnity
  corporation   which   provides   medical,   major-medical   or   similar
  comprehensive-type coverage must provide coverage for the  provision  of
  preventive and primary care services.
    (2)  For  purposes  of  this  subsection,  preventive and primary care
  services shall mean the following services rendered to a dependent child
  of a subscriber 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. Such coverage  shall
  not  be  subject to annual deductibles and/or coinsurance. Such coverage
  shall not restrict  or  eliminate  existing  coverage  provided  by  the
  contract.
    (k)  A  hospital  service  corporation or a health service corporation
  which provides group, group remittance or school  blanket  coverage  for
  inpatient  hospital  care  must  make  available and if requested by the
  contract holder 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,  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  shall  be  at  least
  equal  to the following: (1) with respect to benefits for detoxification
  as a consequence of chemical dependence, inpatient benefits for care  in
  a  hospital  or  detoxification facility may not be limited to less than
  seven days of active treatment  in  any  calendar  year;  and  (2)  with
  respect to benefits for inpatient rehabilitation services, such benefits
  may  not be limited to less than thirty days of inpatient rehabilitation
  in a hospital based or free standing chemical dependence facility in any
  calendar year. 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.   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
  subsection  at  the  first  annual  anniversary date thereafter, without

  evidence of insurability and at any subsequent annual  anniversary  date
  subject  to  evidence  of  insurability. 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  hospital  service  corporation  or
  health  service corporation 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. Such coverage  shall  not  replace,
  restrict  or eliminate existing coverage provided by the policy. Written
  notice of the availability of such coverage shall be  delivered  to  the
  group  remitting  agent  or  group contract holder prior to inception of
  such contract 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.
    (l) A hospital service corporation or  a  health  service  corporation
  which  provides  group,  group remittance or school blanket 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 contract issued pursuant
  to section four thousand three hundred five of this article 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
  substance  abuse  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  hospital  service
  corporation   or  health  service  corporation  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 subsection 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.
    (m) A medical  expense  indemnity  corporation  or  a  health  service
  corporation  which  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  all  subscribers  in  a  group
  remittance group, or by a  contract  holder  in  the  case  of  a  group
  contract  issued pursuant to section four thousand three hundred five of
  this chapter, provide reimbursement for such services when performed  by
  a  duly  licensed  registered professional nurse provided, however, that

  reimbursement shall not be made  for  nursing  services  provided  to  a
  subscriber  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 group remitting agent or group
  contract holder  prior  to  inception  of  such  contract  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.
    (n) In addition to the requirements of subsection (i) of this section,
  every  health service or medical expense indemnity corporation issuing a
  group contract pursuant to this section or a group  remittance  contract
  for  delivery  in  this  state  which contract provides reimbursement to
  subscribers  or   physicians,   psychiatrists   or   psychologists   for
  psychiatric or psychological services or for the diagnosis and treatment
  of  mental, nervous or emotional disorders and ailments, however defined
  in such contract, must provide the  same  coverage  to  persons  covered
  under  the group contract 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 subsection 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  (i) of this section, or (iii) a
  combination of the experience  specified  in  paragraphs  (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
  subsection.
    (o) A hospital service corporation or  a  health  service  corporation
  which  provides coverage for inpatient hospital care must make available
  and, if requested by all persons holding individual contracts in a group
  whose premiums are paid by a remitting agent or by the contractholder in
  the case of a group contract issued pursuant to  section  four  thousand
  three  hundred  five of this article, provide coverage for hospice care.

  For the purposes of this subsection, 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. Hospice care coverage shall be at least equal
  to: (1) 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 (2) five
  visits for bereavement counseling services, either before or  after  the
  insured's  death,  provided to the family of the terminally ill insured.
  Such coverage shall be made  available  at  the  inception  of  all  new
  contracts  and,  with  respect  to contracts 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. 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 contract period. Written notice of  the
  availability  of such coverage shall be delivered to the group remitting
  agent or group contract holder prior to inception of such  contract  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.
    (p) (1) A medical expense indemnity corporation,  a  hospital  service
  corporation  or a health service corporation which provides coverage for
  hospital, surgical or medical care shall provide the following  coverage
  for mammography screening for occult breast cancer:
    (A) upon the recommendation of a physician, a mammogram at any age for
  covered  persons  having  a prior history of breast cancer or who have a
  first degree relative with a prior history of breast cancer;
    (B) a single baseline mammogram for covered persons  aged  thirty-five
  through thirty-nine, inclusive; and
    (C) an annual mammogram for covered persons aged forty and older.
    The  coverage  required  in  this  paragraph  may be subject to annual
  deductibles  and  coinsurance  as  may  be  deemed  appropriate  by  the
  superintendent  and  as  are consistent with those established for other
  benefits within a given policy.
    (2) In no event shall coverage pursuant to this section  include  more
  than one annual screening.
    (3)  For  purposes  of this subsection, mammography screening means an
  X-ray examination of the breast  using  dedicated  equipment,  including
  X-ray  tube,  filter,  compression device, screens, films and cassettes,
  with an average glandular radiation dose less than 0.5 rem per view  per
  breast.
    (q)   (1)   Every   policy  issued  by  a  medical  expense  indemnity
  corporation,  a  hospital  service  corporation  or  a  health   service
  corporation 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.
    (2)  Notwithstanding the provisions of this subsection, 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 subsection 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.
    (r)  Consistent  with federal law, a hospital service corporation or a
  health service corporation 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 a  person
  holding  a  direct payment individual contract or by all persons holding
  individual contracts in a group whose premiums are paid by  a  remitting
  agent  or  by  a  contract holder in the case of a group contract issued
  pursuant to section four thousand three hundred five  of  this  article,
  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  when  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 contracts and, with respect to all
  other contracts at each anniversary date of the contract.
    (1)  Coverage  shall  be subject to a copayment of twenty-five dollars
  per day.
    (2) Brochures describing such coverage must be provided at the time of
  application for all new contracts and  thereafter  on  each  anniversary
  date  of  the contract, and with respect to all other contracts annually
  at each anniversary  date  of  the  contract.  Such  brochures  must  be
  approved  by the superintendent in consultation with the commissioner of
  health.
    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.
    (3)  The  commensurate  rate  for the coverage must be approved by the
  superintendent.
    * (s) (1) A hospital service corporation or health service corporation
  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:
    (A) subject to the provisions of paragraph three of  this  subsection,
  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
    (B) provided, further however,  that  subject  to  the  provisions  of
  paragraph  three  of  this  subsection,  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  subsection,
  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
    (C)  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 paragraph three of this subsection.
    (2)  A  medical  expense indemnity or health service corporation 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:
    (A) subject to the provisions of paragraph three of  this  subsection,
  in  no  case  shall such coverage exclude surgical or medical procedures
  which would correct malformation, disease or  dysfunction  resulting  in
  infertility; and
    (B)  provided,  further  however,  that  subject  to the provisions of
  paragraph three of this subsection,  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 subsection, 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
    (C)  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 paragraph three of this subsection.
    (3)   Coverage  of  diagnostic  and  treatment  procedures,  including
  prescription drugs used in the diagnosis and treatment of infertility as
  required by paragraphs one and two of this subsection shall be  provided
  in accordance with this paragraph.
    (A)  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.
    (B) 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 paragraph.
    (C)  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.
    (D)  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 paragraph "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.
    (E) 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 subparagraph (F) of this paragraph.
    (F) 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 paragraph, 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.
    * NB There are 2 sb (s)'s
    * (s)  Notwithstanding any provision of a contract issued by a medical
  expense indemnity corporation, a dental expense indemnity corporation or
  health service corporation, every contract which provides  coverage  for
  care  provided  through  licensed  health professionals who can bill for
  services shall provide the same  coverage  and  reimbursement  for  such
  service  provided  pursuant  to  a  clinical  practice  plan established
  pursuant to subdivision fourteen of  section  two  hundred  six  of  the
  public health law.
    * NB There are 2 sb (s)'s
    (t)  (1)  A  medical expense indemnity corporation, a hospital service
  corporation or a health service corporation which provides coverage  for
  hospital, surgical, or medical care shall provide coverage for an annual
  cervical cytology screening for cervical cancer and its precursor states
  for  women  aged  eighteen  and  older.  Such coverage may be subject to
  annual deductibles and coinsurance as may be deemed appropriate  by  the
  superintendent  and  as  are consistent with those established for other
  benefits within a given contract.
    (2) For purposes of this subsection, 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.
    (u)  (1)  A  medical expense indemnity corporation or a health service
  corporation 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.
    (2) 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.
    (3) This subsection 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.
    (v)   (1)  Every  contract  issued  by  a  medical  expense  indemnity
  corporation, hospital service corporation or health service  corporation
  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 after such
  covered person has undergone a lymph node dissection or a lumpectomy for
  the treatment of breast cancer or a mastectomy covered by the  contract.
  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
  group remitting agent or group contract holder prior to the inception of
  such contract and annually thereafter.
    (2)  A  medical  expense  indemnity  corporation,   hospital   service
  corporation  or health service corporation which provides coverage under
  this subsection and any participating entity through which  the  insurer
  offers health services shall not:
    (A) deny to a covered person eligibility, or continued eligibility, to
  enroll  or to renew coverage under the terms of the contract or vary the

  terms of the contract for the purpose or with  the  effect  of  avoiding
  compliance with this subsection;
    (B)  provide incentives (monetary or otherwise) to encourage a covered
  person to accept less than the minimum protections available under  this
  subsection;
    (C)  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 subsection;
    (D) provide incentives  (monetary  or  otherwise)  to  a  health  care
  practitioner   relating  to  the  services  provided  pursuant  to  this
  subsection intended to induce  or  have  the  effect  of  inducing  such
  practitioner   to   provide  care  to  a  covered  person  in  a  manner
  inconsistent with this subsection; or
    (E) restrict coverage for any portion of a period  within  a  hospital
  length  of  stay  required  under  this  subsection in a manner which is
  inconsistent with the coverage provided for  any  preceding  portion  of
  such stay.
    (3)  The  prohibitions in paragraph two of this subsection shall be in
  addition to the provisions  of  sections  four  thousand  three  hundred
  seventeen  and  four thousand three hundred eighteen of this article and
  nothing in this paragraph shall  be  construed  to  suspend,  supersede,
  amend or otherwise modify such sections.
    (w)(1)   Every   contract   issued  by  a  medical  expense  indemnity
  corporation or health service corporation 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 contract that requires, or provides financial
  incentives for, the covered person  to  receive  covered  services  from
  health  care providers participating in a provider network maintained by
  or under contract with  the  corporation,  the  contract  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 covered person  beyond  what  such  covered
  person  would  have  paid  for services from a participating appropriate
  specialist. Provided  however  that  nothing  herein  shall  impair  the
  covered person's rights (if any) under the contract 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  contract  for  services provided by non-participating
  providers.  The  corporation  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  contract  that  does not provide financial
  incentives for, and does not require,  the  covered  person  to  receive
  covered  services from health care providers participating in a provider
  network maintained by  or  under  contract  with  the  corporation,  the
  contract  shall  include  coverage  for  a second medical opinion from a
  specialist at no additional cost to the covered person beyond  what  the
  covered person would have paid for comparable services covered under the
  contract.

    (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
  contract and,  where  applicable,  consistent  with  the  provisions  of
  subparagraphs (i) and (ii) of this paragraph.
    Nothing   in   this   subsection   shall  eliminate  or  diminish  the
  corporation's obligation to comply with the provisions of  section  four
  thousand  eight  hundred  four  of  this  chapter and section forty-four
  hundred three of the public health law where applicable. Written  notice
  of  the  availability  of  such coverage shall be delivered to the group
  remitting agent or group contract holder prior to the inception of  such
  contract and annually thereafter.
    (2)   A  medical  expense  indemnity  corporation  or  health  service
  corporation which  provides  coverage  under  this  subsection  and  any
  participating  entity  through  which the insurer offers health services
  shall not:
    (A) deny to a covered person eligibility, or continued eligibility, to
  enroll or to renew coverage under the terms of the contract or vary  the
  terms  of  the  contract  for the purpose or with the effect of avoiding
  compliance with this subsection;
    (B) provide incentives (monetary or otherwise) to encourage a  covered
  person  to accept less than the minimum protections available under this
  subsection;
    (C) 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 subsection; or
    (D)  provide  incentives  (monetary  or  otherwise)  to  a health care
  practitioner  relating  to  the  services  provided  pursuant  to   this
  subsection  intended  to  induce  or  have  the  effect of inducing such
  practitioner  to  provide  care  to  a  covered  person  in   a   manner
  inconsistent with this subsection.
    (3)  The  prohibitions in paragraph two of this subsection shall be in
  addition to the provisions  of  sections  four  thousand  three  hundred
  seventeen  and  four thousand three hundred eighteen of this article and
  nothing in this paragraph shall  be  construed  to  suspend,  supersede,
  amend or otherwise modify such sections.
    (x)(1)   Every   contract   issued  by  a  medical  expense  indemnity
  corporation, hospital service corporation or health service  corporation
  which  provides  coverage for surgical or medical care shall provide the
  following coverage for breast reconstruction surgery after a mastectomy:
    (A) all stages of reconstruction of the breast on which the mastectomy
  has been performed; and
    (B) 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  or
  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 group remitting agent  or  group
  contract  holder  prior  to  the inception of such contract and annually
  thereafter.
    (2)  A  medical  expense  indemnity  corporation,   hospital   service
  corporation  or health service corporation which provides coverage under
  this subsection and any participating entity through which  the  insurer
  offers health services shall not:
    (A) 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 subsection;
    (B)  provide incentives (monetary or otherwise) to encourage a covered
  person to accept less than the minimum protections available under  this
  subsection;
    (C)  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 subsection;
    (D) provide incentives  (monetary  or  otherwise)  to  a  health  care
  practitioner   relating  to  the  services  provided  pursuant  to  this
  subsection intended to induce  or  have  the  affect  of  inducing  such
  practitioner   to   provide  care  to  a  covered  person  in  a  manner
  inconsistent with this subsection;
    (E) restrict coverage for any portion of a period  within  a  hospital
  length  of  stay  required  under  this  subsection in a manner which is
  inconsistent with the coverage provided for  any  preceding  portion  of
  such stay; or
    (F)  the  prohibitions  in  this paragraph shall be in addition to the
  provisions of sections four thousand three hundred  seventeen  and  four
  thousand  three  hundred  eighteen  of  this article and nothing in this
  paragraph shall be construed to suspend, supersede, amend  or  otherwise
  modify such sections.
    * (y)  Every  contract  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  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 sb (y)'s
    * (y)(1) Every contract issued by a health service  corporation  or  a
  medical  expense indemnity corporation which is a "managed care product"
  as defined in paragraph four of this subsection that  includes  coverage
  for  physician services in a physician's office, and every "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.
    (3) Every contract issued by a health service corporation or a medical
  expense  indemnity  corporation  which  includes  coverage for physician
  services in a physician's office,  and  every  contract  which  provides
  major  medical  or  similar  comprehensive-type  coverage,  other than a
  "managed care product" as defined in paragraph four of this  subsection,
  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  than those applicable under the same contract 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.
    (4)  For  purposes  of this subsection, a "managed care product" shall
  mean 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  corporation'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
  corporation's managed care provider network, in order for the insured to
  be entitled to the maximum reimbursement under the contract.
    (5)  The coverage required by this subsection shall not be abridged by
  any regulation promulgated by the superintendent.
    * NB There are 2 sb (y)'s
    (z) No contract issued by a medical expense indemnity  corporation,  a
  hospital  service  corporation  or  a  health  service corporation shall
  exclude coverage of a health care service, as defined in  paragraph  two
  of subsection (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  subsection
  shall  be  provided  subject  to  the  terms  and  conditions  generally
  applicable to other benefits provided under the policy.
    (z-1) (1) 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:
    (A) 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
    (B) 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.
    (2) 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.
    (aa)(1)  Every contract issued by a hospital service company or health
  service  corporation   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.
    (2) 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 subsection, except for the collection of copayments, coinsurance or

  deductibles for which the insured is responsible for under the terms  of
  the policy.
    (3)   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.
    (4)  The  provisions  of  this subsection shall have no application to
  transfers of patients between hospitals or health care facilities by  an
  ambulance service as described in paragraph one of this subsection.
    (5) As used in this subsection:
    (A)   "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 subsection, 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  (i)  placing  the  health  of  the  person
  afflicted  with  such condition in serious jeopardy, or in the case of a
  behavioral condition placing the health of  such  person  or  others  in
  serious  jeopardy;  (ii)  serious  impairment  to  such  person's bodily
  functions; (iii) serious dysfunction of any bodily organ or part of such
  person; or (iv) serious disfigurement of such person.
    (B) "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; (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.
    (bb) A  health  service  corporation  or  a  medical  service  expense
  indemnity   corporation   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:
    (1) For purposes of this subsection, bone mineral density measurements
  or tests, drugs and  devices  shall  include  those  covered  under  the
  criteria  of 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.
    (2) For purposes of this subsection, bone mineral density measurements
  or tests, drugs and devices shall be covered for individuals meeting the
  criteria  for  coverage,  consistent with the criteria under the federal
  medicare 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.
    (cc)  Every  contract  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  contracts  and  certificates  only
  through the addition of a rider.
    (1)   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.
    (A)  For  purposes  of  this  subsection, a "religious employer" is an
  entity for which each of the following is true:
    (i) The inculcation of religious values is the purpose of the entity.
    (ii) The entity primarily employs  persons  who  share  the  religious
  tenets of the entity.
    (iii)  The  entity  serves  primarily  persons who share the religious
  tenets of the entity.
    (iv) 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.
    (B) 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.
    (2)(A) Where a group contractholder makes an election not to  purchase
  coverage for contraceptive drugs or devices in accordance with paragraph
  one  of this subsection, each enrollee covered under the contract issued
  to that group contractholder shall have the right to  directly  purchase
  the  rider  required  by  this  subsection  from  the  insurer or health
  maintenance  organization  which  issued  the  group  contract  at   the
  prevailing  small group community rate for such rider whether or not the
  employee is part of a small group.
    (B) Where a group contractholder makes an  election  not  to  purchase
  coverage for contraceptive drugs or devices in accordance with paragraph
  one  of  this subsection, the insurer or health maintenance organization
  that provides such coverage shall provide written  notice  to  enrollees
  upon  enrollment  with the insurer or health maintenance organization of
  their right to directly purchase a rider for coverage for  the  cost  of
  contraceptive  drugs  or  devices.  The  notice  shall  also  advise the
  enrollees of the additional premium for such coverage.

    (3) Nothing in this subsection shall be  construed  as  authorizing  a
  contract  which  provides  coverage  for  prescription  drugs to exclude
  coverage for  prescription  drugs  prescribed  for  reasons  other  than
  contraceptive purposes.
    (4)  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.
    (dd)   No  health  service  corporation  or  medical  service  expense
  indemnity corporation 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  by  such corporation 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.
    (ee)  A  medical  expense  indemnity  corporation,  a hospital service
  corporation or a health service corporation 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 solely 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.
    * (ff) (1) No  managed  care  contract  issued  by  a  health  service
  corporation,  hospital  service corporation or medical expense indemnity
  corporation 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.
    (2) No managed care contract issued by a health  service  corporation,
  hospital  service  corporation  or medical expense indemnity corporation
  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.
    (3) For purposes of this subsection, 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.
    (4)  For  purposes  of this subsection, a "managed care contract" is a
  contract  that  requires  that  services  be  provided  by  a   provider
  participating  in  the corporation's network in order for the subscriber
  to receive the maximum level of reimbursement under the contract.
    * NB Effective January 1, 2010