NY Insurance Law

Article 43
Non Profit Medical and Dental
indemnity or Health and Hospital
Service Corporations

ARTICLE 43
         NON-PROFIT MEDICAL AND DENTAL INDEMNITY, OR HEALTH AND
                      HOSPITAL SERVICE CORPORATIONS
Section  4301.   Organization   of   corporation;   purposes;  board  of
                   directors.
         4302.   Permit and license to do business.
         4303.   Benefits.
         4304.   Individual contracts.
         4305.   Group contracts.
         4306.   Required contract provisions.
         4306-a. Health insurance coverage  for  full-time  students  on
                   medical leaves of absence.
         4306-b. Primary and preventive obstetric and gynecologic care.
         4307.   Providers of services.
         4308.   Supervision of superintendent; public hearings.
         4309.   Limitation on expenses.
         4310.   Investments; financial conditions; reserves.
         4311.   Records to be made available by corporations subject to
                   this article.
         4312.   Employment of solicitors; pension plans.
         4313.   Applicability of other provisions of this chapter.
         4314.   Not to affect provisions of workers` compensation law.
         4315.   Arbitration; judicial review.
         4316.   Individual   contracts;  premium  refund  at  death  of
                   insured.
         4317.   Rating of individual and small group  health  insurance
                   contracts.
         4318.   Pre-existing condition provisions.
         4318-a. Certification  of  creditable  coverage by corporations
                   organized under this article.
         4320.   Limitations on administrative  services  and  stop-loss
                   coverage.
         4321.   Standardization  of  individual enrollee direct payment
                   contracts    offered    by     health     maintenance
                   organizations.
         4321-a  Fund   for   standardized  individual  enrollee  direct
                   payment contracts.
         4322.   Standardization of individual enrollee  direct  payment
                   contracts offered by health maintenance organizations
                   which provide out-of-plan benefits.
         4322-a. Fund   for   standardized  individual  enrollee  direct
                   payment contracts which provide out-of-plan benefits.
         4323.   Marketing materials.
         4324.   Disclosure of information.
         4325.   Prohibitions.
         4326.   Standardized health insurance contracts for  qualifying
                   small employers and individuals.
         4327.   Stop  loss  funds  for  standardized  health  insurance
                   contracts issued to qualifying  small  employers  and
                   qualifying individuals.

  S 4301. Organization of corporation; purposes; board of directors. (a)
A corporation may be organized under the not-for-profit corporation law,
and a consumers` cooperative stock corporation may be organized under
article two of the cooperative corporations law, for the purpose of
furnishing medical expense indemnity, dental expense indemnity, hospital
service, or health service or, upon compliance with the applicable
provisions of subsection (h) of this section, both medical expense
indemnity and hospital service, to persons who become covered under
contracts with such corporations.
  (b) (1) Medical expense indemnity shall consist of reimbursement for:
  (A) medical care provided through licensed physicians,
  (B) dental care provided through licensed dentists,
  (C) optometric care provided through licensed optometrists,
  (D) podiatrical care provided through licensed podiatrists,
  (E) chiropractic care provided through licensed chiropractors,
  (F) psychiatric or psychological services provided through physicians,
psychiatrists or certified and registered psychologists,
  (G) physical and occupational therapy care provided through licensed
physical and occupational therapists upon the prescription of a
physician,
  (H) nursing service,
  (I) speech-language pathology or audiology services provided through
licensed speech-language pathologists or audiologists, provided however,
that nothing contained herein shall be construed to prohibit a contract
from requiring said service from being performed pursuant to a medical
order or similar or related service of a physician, in which case
coverage need not be provided for any tests, evaluations or diagnoses if
such tests, evaluations or diagnoses have already been provided by or
through a physician within twelve months of the referral or order from
the physician. However, nothing herein shall be construed as preventing
a corporation from covering more than one test or evaluation provided by
a speech-language pathologist or audiologist within a twelve-month
period where such tests or evaluations is ordered by a physician as
medically necessary. Nor shall anything herein be construed as
prohibiting the limitation of such services, where covered, to specified
settings other than offices, such as hospitals or to services provided
by such professionals as part of a home care agency`s services,
  (J) necessary appliances, drugs, medicines and supplies, and
  (K) bio-analytical or clinical laboratory examinations and reports
thereof reported to a physician, osteopath, dentist, optometrist,
podiatrist, chiropractor or physical therapist made by any privately
operated bioanalytical or clinical laboratory.
  (2) It is not mandatory that a contract issued by a medical expense
indemnity corporation provide for and offer all of the services
hereinabove described, but when any service is provided which can be
performed by more than one of the practitioners hereinbefore referred
to, benefits under the contract shall be provided regardless of which
practitioner performed the service, provided that the performance of
such service was within the scope of the license of such practitioner.
Unless such contract shall otherwise provide there shall be no
reimbursement for ophthalmic materials, lenses, spectacles, eyeglasses,
and/or appurtenances thereto.
  (3) Every medical expense indemnity corporation shall be open to the
participation of licensed physicians, podiatrists, chiropractors,
optometrists, physical and occupational therapists, speech-language
pathologists, audiologists, and dentists, certified and registered
psychologists without discrimination against schools of medical
practice, podiatry practice, chiropractic practice, optometric practice,
physical and occupational therapy practice, dental practice,
speech-language pathology practice (subject to the permitted limitations
of paragraph one of this subsection), audiology practice (subject to the
permitted limitations of paragraph one of this subsection), and
psychological training as defined in the education law.
  (c) Dental expense indemnity shall consist of reimbursement for dental
care provided through licensed dentists and of furnishing necessary
appliances, drugs, medicines, and supplies, prosthetic appliances,
orthodontic appliances, precious metal and ceramic restorations.
  (d) (1) Hospital service shall consist of in-patient hospital care and
out-patient hospital care when such hospital care is provided through a
hospital which is maintained by the state or any of its political
subdivisions, or maintained by a corporation organized for hospital
purposes under the laws of this state, or such other hospitals as shall
be designated by the state department of health, and hospitals of other
states subject to the supervision of such other state, convalescent care
provided by any convalescent institution, or nursing care provided by
any nursing home.
  (2) A hospital service corporation may also provide reimbursement for
expenses incurred outside of the hospital, convalescent institution or
nursing home, for nursing service, necessary appliances, drugs,
medicines, supplies, and any other services which would have been
available in the hospital, convalescent institution or nursing home
(excluding physicians` services), whether or not provided through a
hospital, convalescent institution or nursing home.
  (3) A hospital service corporation may also furnish reimbursement for
ambulance service expenses.
  (e) (1) Health service, as used in this article, shall consist of the
types of services referred to in this section.
  (2) A health service corporation, in any hospital, facility or center
directly operated by it may provide hospital or medical care to persons
other than persons covered under contracts issued by such corporation.
  (3) A health service corporation may:
  (A) exercise all of the powers of a medical expense indemnity, dental
expense indemnity and hospital service corporation;
  (B) organize, manage and promote a health maintenance organization as
such term is defined in article forty-four of the public health law;
  (C) contract or otherwise act jointly with a hospital corporation
organized under article twenty-eight of the public health law, a
hospital service corporation organized pursuant to this article, a
health maintenance organization possessing a certificate of authority
pursuant to article forty-four of the public health law, a professional
service corporation organized under article fifteen of the business
corporation law, a university faculty practice corporation organized
under section fourteen hundred twelve of the not-for-profit corporation
law or a partnership for the purpose of organizing, managing and
promoting such prepaid comprehensive health services plan;
  (D) contract or otherwise act jointly with an insurance company,
authorized to do an accident and health insurance business in this
state, for the purpose of organizing, managing and promoting such a
health maintenance organization.
  (4) A health service corporation engaged in providing medical care
through medical groups, hospital services and dental care, may include
as a component of its rate a sum of five per centum of such rate to be
used for the purchase or construction of facilities for the conduct of
its business, and for the implementation of its program, or for making
loans for the purposes of implementing the program of such corporation.
  (5) To encourage the development in this state of health maintenance
organizations as such term is defined in article forty-four of the
public health law, the superintendent may modify any requirement
applicable to health service corporations and other corporations
organized under this article to permit such corporations to make fuller
use of their resources in the development of such plans, including the
acquisition and construction of hospitals, medical service centers and
other health facilities and the equipment therefor, subject to such
limitations as the superintendent shall deem necessary or proper to
ensure the performance of contracts issued by such corporations and to
protect the interests of persons covered under such contracts.
  (6) Any other corporation subject to the provisions of this article
may by appropriate amendment to its certificate of incorporation become
a health service corporation.
  (f) No foreign or alien medical expense indemnity corporation, dental
expense indemnity corporation, health service corporation, or hospital
service corporation shall be authorized to do business in this state. No
person, firm, association or corporation shall in this state furnish or
contract to furnish medical expense indemnity, dental expense indemnity,
hospital service or health service under any insurance plan unless
authorized so to do under the provisions of this chapter.
  (g) Two or more corporations organized pursuant to the provisions of
this article may, upon compliance with the applicable provisions of
article seventy-one of this chapter, consolidate, if the superintendent
finds that such consolidation will promote the public interest. No
corporation resulting from any such consolidation shall operate in any
county in which none of the corporations so consolidated was empowered
to operate immediately prior to such consolidation.
  (h) A medical expense indemnity corporation or a hospital service
corporation may, pursuant to a plan submitted to and approved by the
superintendent, furnish both medical expense indemnity and hospital
service benefits, as these are defined in subsections (b) and (d) of
this section, by amending its certificate or act of incorporation in the
manner provided in the applicable provisions of the not-for-profit
corporation law and the cooperative corporations law. Except as the
context otherwise requires, a corporation writing both medical expense
indemnity and hospital service benefits shall be subject to all of the
provisions of this article applicable to medical expense indemnity and
hospital service corporations.
  (i) Subject to the provisions of the preceding subsections, a hospital
service corporation and a medical expense indemnity corporation and a
dental expense indemnity corporation or any two of such corporations may
issue a combined contract providing for hospital service, medical
expense indemnity or dental expense indemnity, but no one of such
corporations shall issue any such combined contract unless it complies
with the applicable provisions of subsection (h) hereof. A hospital
service corporation and a medical expense indemnity corporation and a
dental expense indemnity corporation or any two of such corporations may
underwrite jointly in such a combined contract such benefits as each
might otherwise individually provide under this article. Any one of such
corporations may act as agent for the other without being required to
obtain a license as an agent under article twenty-one of this chapter.
  (j) (1) No medical expense indemnity corporation, dental expense
indemnity corporation, health service corporation, or hospital service
corporation shall be converted into a corporation organized for
pecuniary profit. Every such corporation shall be maintained and
operated for the benefit of its members and subscribers as a
co-operative corporation.
  (2) An article forty-three corporation which was the subject of an
initial opinion and decision issued by the superintendent on or before
December thirty-first, nineteen hundred ninety-nine, as the same may be
amended, may be converted into a corporation or other entity organized
for pecuniary profit, or into a for-profit organization, in any such
case, in accordance with the provisions of section seven thousand three
hundred seventeen of this chapter.
  (3) For the purposes of this subsection and section seven thousand
three hundred seventeen of this chapter, "public asset" shall mean
assets representing ninety-five percent of the fair market value of the
corporation seeking to convert into a corporation or other entity
organized for pecuniary profit pursuant to paragraph two of this
subsection. Fair market value, as defined in subsection (l) of section
seven thousand three hundred seventeen of this chapter, shall be
determined as of the date the superintendent approves the conversion
transaction pursuant to subsection (f) of section seven thousand three
hundred seventeen of this chapter.
  (4) In addition to any other requirements of law, rule or regulation,
the following requirements shall be applicable to the public asset:
  (A) The public asset shall be transferred to the fund established
pursuant to subsection (e) of section seven thousand three hundred
seventeen of this chapter and the public asset shall be irrevocably
dedicated to the purpose as set forth in such section;
  (B) There is hereby established a board for the purpose of advising
and making decisions with respect to the investment of assets and moneys
in the fund created pursuant to subsection (e) of section seven thousand
three hundred seventeen of this chapter. Such board shall be composed of
five members appointed as follows: three members shall be appointed by
the governor; one member appointed by the temporary president of the
senate; and one member appointed by the speaker of the assembly. Each
member of the board shall be appointed for a term of three years and may
be reappointed at the end of said term by the same person that made the
original appointment. A vacancy in the membership of the board shall be
filled for the unexpired portion of the term provided for by the
original appointment by the same person that made the original
appointment. Each member may be removed, other than upon the expiration
of his or her term, only for neglect of duty, misconduct or other good
cause. Each member of the board shall be a member of the public with
knowledge and expertise in capital markets and a demonstrated commitment
to ensuring continued access to, and availability of, health care
services and may not be an officer or employee of the state or any
municipal subdivision thereof;
  (C) The members shall serve without compensation for their services as
members, but shall be entitled to reimbursement for actual and necessary
expenses incurred in the performance of their official duties. Such
members, except as otherwise provided by law, may engage in private
employment, or in a profession or business;
  (D) The board and its corporate existence shall continue until there
are no longer any assets or moneys in the fund created pursuant to
subsection (e) of section seven thousand three hundred seventeen of this
chapter available for distribution;
  (E) The affirmative vote of three of the members shall be necessary
for the transaction of any business or the exercise of any power or
function of the board. The board may delegate to one or more of its
members, or its agents, such powers and duties as it may deem proper;
  (F) The board shall have the power to:
  (i) direct, in consultation with the director of the division of the
budget regarding the anticipated schedule of payments to the state, the
manner in which moneys in the fund created pursuant to subsection (e) of
section seven thousand three hundred seventeen of this chapter are
invested so as to maximize the value of the assets in such fund
consistent with the board`s statutory obligation to direct disbursements
as described below and in subsection (e) of section seven thousand three
hundred seventeen of this chapter;
  (ii) direct that disbursements be made from such fund in accordance
with the direction of the director of the division of the budget and as
described in subsection (e) of section seven thousand three hundred
seventeen of this chapter; and
  (iii) make and execute contracts and all other instruments, and to
exercise such other powers, necessary or convenient for the exercise of
its powers and functions.
  In directing investments pursuant to this subparagraph, the board
shall not be limited by any restrictions on investments contained in any
other section of law, subject only to the board`s obligations and the
considerations set forth above;
  (G) Neither the members of the board nor any agent or other person or
persons acting on its behalf, while acting within the scope of their
authority as members or agents of the board, shall be subject to any
personal liability resulting from the carrying out of the powers
conferred hereunder;
  (H) Any action or proceeding in which any question arises as to the
validity of any provision in this subsection or in section seven
thousand three hundred seventeen of this chapter, shall be preferred
over all other civil causes except election causes in all courts of the
state of New York and shall be heard and determined in preference to all
other civil business pending therein except election causes,
irrespective of position on the calendar. The same preference shall be
granted upon application of counsel to the board in any action or
proceeding questioning the validity of any provision herein in which he
or she may be allowed to intervene;
  (I) To assist in carrying out its functions, the board shall be
authorized to hire independent financial, legal and other experts and
consultants;
  (J) Inconsistent provisions of other laws are superseded. Insofar as
any provision in this section is inconsistent with the provisions of any
other law, general, special or local, the provisions in this section
shall be controlling;
  (K) This section, being necessary for the welfare of the state and its
inhabitants, shall be liberally construed so as to effectuate its
purposes;
  (L) Each member of the board shall be and shall remain independent of
any control or influence by the surviving corporation or other surviving
entity organized for pecuniary profit and its affiliates and successors.
Such requirement shall not prevent the board from voting its equity
shares in the for-profit organization in accordance with the voting and
shareholders rights agreement. No person who is an officer, director or
employee of the corporation seeking conversion at the time such
corporation applies to the superintendent for permission to convert
shall be a member of the board;
  (M) The board shall establish formal mechanisms to avoid conflicts of
interest;
  (N) The board shall enter into an asset preservation agreement with
the converted corporation; and
  (O) Notwithstanding any other provision of law, the board shall direct
that such proceeds of the public asset are disbursed in accordance with
direction from the director of the division of the budget and
transferred to the credit of the tobacco control and insurance
initiatives pool, or its successor to be used for the exclusive purposes
provided therein.
  (5) For the purpose of this subsection and section seven thousand
three hundred seventeen of this chapter, "charitable asset" shall mean
assets representing five percent of the fair market value of the
corporation seeking to convert into a corporation or other entity
organized for pecuniary profit pursuant to paragraph two of this
subsection. Fair market value, as defined in subsection (l) of section
seven thousand three hundred seventeen of this chapter, shall be
determined as of the date the superintendent approves the conversion
transaction pursuant to subsection (f) of section seven thousand three
hundred seventeen of this chapter. If one hundred percent of the stock
is not transferred in connection with the conversion transaction, the
proportion of stock to cash that is distributed as the charitable asset
shall be the same as the proportion of stock to cash that is distributed
as the public asset.
  (k) (1) The board of directors of each health service, hospital
service or medical expense indemnity corporation subject to this article
shall be composed of persons who are representative of the member
hospitals or licensed medical professionals of such corporation, persons
covered under its contracts and the general public. The board of
directors of such corporations may also include persons who are
employees of such corporations and who also serve as officers of such
corporations. Not more than one-fifth of the directors of any such
corporation shall be persons who are licensed to practice medicine in
this state (other than physicians employed on a full-time basis in the
fields of public health, public welfare, medical research or medical
education) or who are trustees, directors or employees of a corporation
organized for hospital purposes, or any combination thereof. Not more
than one-eighth of the directors of any such corporation shall be
persons who are employees of such corporation and who also serve as
officers of such corporation. Any person who is an officer of such
corporation but not an employee of such corporation shall be considered
under one of the other classifications of directors set forth in this
section, as appropriate. Whenever the maximum number of directors in
either of the classifications set forth in the preceding sentences
includes a fractional number equal to or greater than one-half, the
number shall be rounded to the next greater whole number. Whenever the
maximum number of directors in either of the classifications set forth
in the preceding sentences includes a fractional number less than
one-half, the number shall be rounded to the next lesser whole number.
Of the directors not included in the classifications set forth in the
preceding sentences,
  (A) one-half in number, as nearly as possible, shall be persons
covered under a contract or contracts issued by such health service,
hospital service or medical expense indemnity corporation, and who are
generally representative of broad segments of such covered persons, and
  (B) one-half in number, as nearly as possible, shall be persons whose
background and experience indicate that they are qualified to act in the
broad public interest, whether or not they are persons covered under a
contract or contracts issued by such health service, hospital service or
medical expense indemnity corporation.
  (C) A person who, or whose spouse or minor child, is an officer,
director, or owner of more than ten per centum of the stock of a
corporation whose aggregate sales to hospitals and licensed medical
professionals and to facilities of a health service, hospital service or
medical expense indemnity corporation exceed five per centum of its
total sales may not serve as a director under subparagraph (A) or (B)
hereof.
  (D) Each such health service, hospital service or medical expense
indemnity corporation shall have an executive committee the members of
which shall be composed, as nearly as possible, of representatives of
any member hospitals or licensed medical professionals of such
corporation, employee-officers of such corporation, persons covered
under its contracts and the general public in the same proportions as
the membership of the board of directors.
  (E) The board of directors of a health service, hospital service or
medical expense indemnity corporation with a combined premium volume
exceeding two billion dollars annually as of December thirty-first,
nineteen hundred ninety-six shall, in addition to its other
responsibilities, have responsibility for ensuring that the corporation
implements and maintains effective standards and procedures for
operating efficiency and for quality of consumer service and claims
payment, including but not limited to coordination of benefits and fraud
prevention and shall establish one or more committees comprised solely
of directors who are not officers or employees of the corporation. Such
committee or committees shall have responsibility for recommending the
selection of independent certified public accountants, reviewing the
corporation`s financial condition, the scope and results of the
independent audit and any internal audit, nominating candidates for
director for election by members, and evaluating the performance of
officers deemed by such committee or committees to be principal officers
of the company and recommending to the board of directors the selection
and compensation of such principal officers.
  (2) (A) Compliance with the provisions of paragraph one hereof shall
be under the supervision of the superintendent.
  (B) Within ten days after a vacancy in the board of directors of a
health service, hospital service or medical expense indemnity
corporation shall occur, such corporation shall notify the
superintendent in writing that such vacancy exists. Not more than ten
days after the election of a person as a director of a health service,
hospital service or medical expense indemnity corporation, such
corporation shall furnish, in writing, the following information to the
superintendent: the name and address of the person so elected; whether
such person is representative of any member hospital or licensed medical
professional of such corporation or persons covered under its contracts
or the general public and qualified to serve pursuant to the provisions
of paragraph one hereof or is an employee-officer of such corporation;
and a biographical statement concerning such person. If the
superintendent finds, after a hearing, that the composition of the board
of directors of a health service, hospital service or medical expense
indemnity corporation is not in compliance with the provisions of
paragraph one hereof, he may direct that such board of directors be
reconstituted in accordance with his finding.
  (3) No person who has served as a director of any corporation subject
to this article for ten consecutive years shall thereafter be elected
for an additional term of office as such until at least one year has
elapsed since the expiration of his prior term of office. The preceding
sentence shall not apply to a director of any corporation subject to
this article who is an employee of the corporation and who also serves
as an officer of the corporation. The superintendent, upon application
by a corporation subject to the provisions of this article, may waive
the ten year limit in this paragraph for a non-employee serving as
chairman of its board of directors.
  (4) A director of a corporation subject to this article shall
automatically forfeit his office if (i) he fails to attend at least one
of the regular meetings of the board of directors held during any period
of eighteen consecutive months, or (ii) unless excused by the board of
directors of which he is a member, which action shall be entered on the
minutes of such board, it shall appear at the end of any calendar year
that he failed to attend at least one-half of the regular meetings of
such board held in such calendar year. A director whose office becomes
vacant pursuant to the provisions of this paragraph shall not be
eligible for election to such office for a period of one year from the
date the vacancy occurred.

  S 4302. Permit and license to do business. (a) Corporations subject to
this article shall not solicit the purchase of, or enter into, any
contract with any individual or group until it has obtained from the
superintendent a permit so to do. Such permit shall be issued by the
superintendent upon receipt of an application in a form to be prescribed
by the superintendent and upon payment of a fee of ten dollars. Such
application shall include a statement of the territory in which the
corporation will operate, which, in the case of hospital service
corporations, shall not exceed eighteen counties of this state, the
services to be rendered by the corporation and the rates to be charged
therefor, and shall be accompanied by two copies of each type of
contract for service which the corporation proposes to render and by a
bond in the sum of one thousand dollars conditioned upon return to
applicants for contracts of any advance payments made if within one year
from the date of the issuance of such permit a license to do business as
hereafter provided has not been issued.
  (b) No such corporation shall furnish medical expense indemnity,
dental expense indemnity, hospital service or health service as set
forth in section four thousand three hundred one of this article until
it has obtained from the superintendent a license to do business. Such
license may be issued by the superintendent upon the filing of an
application, subscribed by two officers of such corporation and affirmed
by such officers as true under the penalties of perjury, and in a form
prescribed by the superintendent and upon payment of a fee of ten
dollars. Such application shall include (i) a statement of the number of
individuals and groups from whom the corporation has received
applications for medical expense indemnity, dental expense indemnity,
hospital service or health service, as the case may be, to be rendered
during one year, and from each of whom it has received payment of not
less than one-sixth of the full payment required from such individuals
and groups; and (ii) a statement of the total amount so collected, which
shall be not less than eighteen hundred dollars. Before issuing any such
license the superintendent may make such examination or investigation as
he deems expedient, including an investigation of the sponsors of such
proposed corporation and if after such examination or investigation he
determines the issuance of such license is contrary to the interest of
the people, he shall refuse to issue. Upon the issuance of such license,
the corporation may begin to furnish medical expense indemnity, dental
expense indemnity, hospital service or health service, as the case may
be.
  (c) Notwithstanding the other provisions of this article, the
superintendent may issue a permit to organize and a license to do
business to a not-for-profit corporation organized and operated under
the supervision of the New York State Public High School Athletic
Association, unrestricted as to its territorial operations in this
state, for the sole purpose, however, of furnishing medical, dental and
hospital expense indemnity to bona fide students in elementary and high
schools injured (i) in intramural and interscholastic athletic games and
sports activities, (ii) while engaged in preparation for such games,
sports or contests, (iii) in physical education classes, and (iv) in any
other accidents which in the judgment of the superintendent should be
included. The dental indemnity is to apply, however, only in case of
dental expense caused by injury occurring as above set forth.

  S 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. S 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.
  * NB Effective until December 31, 2003
  * (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 skilled nursing facility as
defined in subchapter XVIII of the Social Security Act, 42 U.S.C. S 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.
  * NB Effective December 31, 2003
  * (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.
  * NB Effective until December 31, 2003
  * (B) Home care shall be provided by a certified home health agency
possessing a valid certificate of approval issued pursuant to article
thirty-six of the public health law.
  * NB Effective December 31, 2003
  * (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. S 1395 et seq.
  * NB Effective until December 31, 2003
  * (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 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. S 1395 et seq.
  * NB Effective December 31, 2003
  (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. S 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. S 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. S 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 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 contract
holder in the case of a group contract issued pursuant to section four
thousand three hundred five of this article, provide coverage for the
diagnosis and treatment of mental, nervous or emotional disorders or
ailments, however defined in such contract, at least equal to the
following:
  (A) with respect to benefits based upon confinement as an in-patient
in a hospital as defined by subdivision ten of section 1.03 of the
mental hygiene law, such benefits may be limited to not less than thirty
days of active treatment in any calendar year;
  (B) with respect to benefits for out-patient care provided in a
facility issued an operating certificate by the commissioner of mental
hygiene pursuant to the provisions of article thirty-one of the mental
hygiene law or in a facility operated by the department of mental
hygiene such benefits may be limited to not less than seven hundred
dollars in any calendar year.
  (2) 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. Such coverage may be subject
to annual deductibles and coinsurance as may be deemed appropriate by
the superintendent. Such deductibles and coinsurance may be consistent
with those imposed on other benefits within a given contract. 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
hygiene. If the group remittance group or contract holder in the case of
a group contract also has coverage from the same health service
corporation or from a medical expense indemnity corporation or another
health service corporation for physicians` services, the health service
corporation shall not provide the coverage under this subsection unless
the group remittance group or contract holder also obtains the coverage
provided under subsection (h) of this section. In the event the group
remittance group or contract holder obtains the coverage under this
subsection and under subsection (h) 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 outpatient care obtained under subparagraph (B) of
paragraph one of this subsection and subsection (h) of this section may
be limited to not less than seven hundred dollars in any calendar year.
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.
  * (h) A medical expense indemnity corporation or a health service
corporation which provides coverage for physician services 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
coverage for the diagnosis and treatment of mental, nervous or emotional
disorders or ailments, however defined in such contract, at least equal
to the following: with respect to benefits for outpatient care provided
by a psychiatrist or psychologist licensed to practice in this state, a
certified social worker who meets the requirements of subsection (n) of
this section, or a professional corporation or university faculty
practice corporation thereof, such benefits may be limited to not less
than seven hundred dollars in any calendar year. 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. Such coverage may be subject to annual deductibles and
coinsurance as may be deemed appropriate by the superintendent. Such
deductibles and coinsurance may be consistent with those imposed on
other benefits within a given contract. If the group remittance group or
contract holder in the case of a group contract also has coverage from
the same health service corporation or from another health service
corporation for in-patient hospital care, the medical expense indemnity
corporation or the health service corporation shall not provide the
coverage under this subsection unless the group remittance group or
contract holder also obtains the coverage provided under subparagraph
(B) of paragraph one of subsection (g) of this section. In the event the
group remittance group or contract holder obtains the coverage provided
under this subsection 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 subsection may be limited to not less than
seven hundred dollars in any calendar year. 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.
  * NB Effective until September 1, 2004
  * (h) A medical expense indemnity corporation or a health service
corporation which provides coverage for physician services 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
coverage for the diagnosis and treatment of mental, nervous or emotional
disorders or ailments, however defined in such contract, at least equal
to the following: with respect to 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, such benefits may be limited to not less
than seven hundred dollars in any calendar year. 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. Such coverage may be subject to annual deductibles and
coinsurance as may be deemed appropriate by the superintendent. Such
deductibles and coinsurance may be consistent with those imposed on
other benefits within a given contract. If the group remittance group or
contract holder in the case of a group contract also has coverage from
the same health service corporation or from another health service
corporation for in-patient hospital care, the medical expense indemnity
corporation or the health service corporation shall not provide the
coverage under this subsection unless the group remittance group or
contract holder also obtains the coverage provided under subparagraph
(B) of paragraph one of subsection (g) of this section. In the event the
group remittance group or contract holder obtains the coverage provided
under this subsection 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 subsection may be limited to not less than
seven hundred dollars in any calendar year. 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.
  * NB Effective September 1, 2004
  * (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 social worker, within the lawful scope of
his practice, who is certified pursuant to article one hundred
fifty-four of the education law and in addition shall have either (1)
three years post degree experience in psychotherapy, which for the
purposes of this subsection means 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 (2) three years post degree experience in psychotherapy
under the supervision, satisfactory to the state board for social work,
of a psychiatrist, a certified and registered psychologist or a social
worker qualified for reimbursement. The state board for social work
shall maintain a list of all certified 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.
  * NB Effective until September 1, 2004
  * (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 and in addition shall have
either (1) three years post degree experience in psychotherapy, which
for the purposes of this subsection means 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 (2) three years post degree 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. 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.
  * NB Effective September 1, 2004
  (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 social worker, within the lawful scope of his or her
practice, who is certified pursuant to article one hundred fifty-four of
the education law and in addition shall have either (i) six or more
years post degree 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) six or
more years post degree experience in psychotherapy under the
supervision, satisfactory to the state board for social work, of a
psychiatrist, a certified and registered psychologist or a 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 six years, satisfactory to the state board for social
work. The state board for social work shall maintain a list of all
certified social workers qualified for reimbursement under this
subsection.
  * NB Effective until September 1, 2004
  * (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 article one
hundred fifty-four of the education law and in addition shall have
either (i) six or more years post degree 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) six or more years post degree 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 six 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.
  * NB Effective September 1, 2004
  (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 SS 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 legally blind, data management systems, test
strips for glucose monitors and visual reading and urine testing strips,
insulin, injection aids, cartridges for the legally blind, 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.
  (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.

  S 4304. Individual contracts. (a) Every corporation subject to the
provisions of this article may issue a contract to an individual the
premiums for which may be paid to the corporation directly by the
individual or by a remitting agent for the group to which the individual
belongs. If the premiums for a contract issued pursuant to this section
are paid to the corporation by a remitting agent, such contract shall be
subject to subsections (k) and (l) of section four thousand two hundred
thirty-five of this chapter, and for the purposes of these subsections,
the remitting agent shall be treated as the policyholder.
  (b)(1) Any such contract shall be for a period not in excess of twelve
months, but no contract shall be made providing for the inception of
benefits at a date later than one year from the date of the contract.
  (2) Any such contract shall provide that it will be automatically
renewed from year to year unless there shall have been one month`s prior
written notice of termination by the subscriber.
  (3) No corporation shall refuse to renew any such contract because of
the physical or mental condition or the health of any person covered
thereunder. The provisions of this subsection shall in no way diminish
the rights of individuals pursuant to section four thousand three
hundred seventeen of this article.
  (c) Any such contract may be terminated in the following manner:
  (1) At the option of the individual to whom the contract is issued,
upon not less than one month`s prior written notice.
  (2) At the option of the corporation, for one or more of the following
reasons:
  (A) The individual has failed to pay premiums or contributions in
accordance with the terms of the contract or the corporation has not
received timely premium payments.
  (B) The individual has performed an act or practice that constitutes
fraud or made an intentional misrepresentation of material fact under
the terms of the contract, upon not less than one month`s prior written
notice.
  (C) (i) Discontinuance of a class of contract upon not less than five
months` prior written notice, except for subscribers to direct pay major
medical or similar comprehensive-type coverage issued by a corporation
organized pursuant to this article, or any successor corporation
organized through a conversion pursuant to subsection (j) of section
four thousand three hundred one of this article, and in effect prior to
January first, nineteen hundred ninety-six who are ineligible to
purchase policies offered after such date pursuant to section four
thousand three hundred twenty-one or four thousand three hundred
twenty-two of this article due to the provisions of 42 U.S.C. 1395ss in
effect on the effective date of this item. In the event any such
subscriber becomes eligible to purchase policies offered pursuant to
section four thousand three hundred twenty-one or four thousand three
hundred twenty-two of this article, then such subscriber may be
discontinued upon not less than five months` prior written notice. In
exercising the option to discontinue coverage pursuant to this item, the
corporation must act uniformly without regard to any health
status-related factor of enrolled individuals or individuals who may
become eligible for such coverage and must offer to subscribers or group
remitting agents, as may be appropriate, the option to purchase all
other individual health insurance coverage currently being offered by
the corporation to applicants in that market.
  (ii) Discontinuance of all hospital, surgical or medical expense
coverage in the individual direct payment market in this state upon
written notice to the superintendent and to each subscriber not less
than one hundred eighty days prior to the date of the expiration of such
coverage. In the event of such a withdrawal from the individual direct
payment market, the corporation must also provide the superintendent
with a written plan to minimize potential disruption in the marketplace
occasioned by such withdrawal. In addition, the corporation may not
provide for the issuance of any hospital, surgical or medical expense
coverage in the individual direct payment market in this state during
the five-year period beginning on the date of the discontinuance of the
last health insurance coverage not so renewed.
  (iii) Discontinuance of all individual hospital, surgical or medical
expense insurance contracts for which the premiums are paid by a
remitting agent of a group, in the small group market, or the large
group market, or both markets, in this state, in conjunction with a
withdrawal from the small group market, or the large group market, or
both markets, in this state. Withdrawal from the small group market, or
the large group market, or both markets, shall be governed by the
requirements of subparagraphs (B) and (C) of paragraph three of
subsection (j) of section four thousand three hundred five of this
article. For purposes of this item, "withdrawal" from a market means
that no coverage is offered or maintained in such market under contracts
issued pursuant to this section or contracts issued pursuant to section
four thousand three hundred five of this article.
  (D) In the case of a corporation that offers health insurance in the
market through a network plan, the individual no longer resides, lives
or works in the service area (or in an area for which the corporation is
authorized to do business) but only if such coverage is terminated under
this paragraph uniformly without regard to any health status-related
factor of covered individuals. For the purposes of this subparagraph,
the term "network plan" means health insurance coverage of a corporation
organized under this article under which the financing and delivery of
health care (including items and services paid for as such care) are
provided, in whole or in part, through a defined set of providers under
contract either with the corporation or another entity that has
contracted with the corporation.
  (E) In case of a contract for which the premiums are paid by a
remitting agent of a group, discontinuance of the individual`s
membership in such group.
  (F) Such other reasons as the superintendent may approve and
authorized by the Health Insurance Portability and Accountability Act of
1996, Public Law 104-191, and any later amendments or successor
provisions, or by any federal regulations or rules that implement the
provisions of the Act, upon not less than one month`s prior written
notice.
  (3) Every notice of termination shall be in a form satisfactory to the
superintendent and shall include a statement of the conversion
privileges, if any, upon such termination.
  (4) In the event of termination of a contract, the corporation shall
return the unearned portion of the premium.
  (d) (1) No contract issued pursuant to this section shall entitle