S05800 Summary:

BILL NOS05800
 
SAME ASSAME AS A08460
 
SPONSORSEWARD
 
COSPNSR
 
MLTSPNSR
 
Amd Ins L, generally; amd SS4403, 4406-b, 4900, 4910, 4912 & 4914, Pub Health L
 
Relates to prescription drug coverage, pre-existing conditions and preventive health care; increases the age of dependent children; provides for choice of health care providers; relates to pediatric care; prohibits lifetime and annual coverage limits; eliminates certain appeal requirements; allows commissioner to devise and implement regulations pertaining thereto.
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S05800 Actions:

BILL NOS05800
 
06/17/2011REFERRED TO RULES
06/20/2011ORDERED TO THIRD READING CAL.1376
06/20/2011PASSED SENATE
06/20/2011DELIVERED TO ASSEMBLY
06/20/2011referred to insurance
06/22/2011substituted for a8460
06/22/2011ordered to third reading rules cal.587
06/22/2011passed assembly
06/22/2011returned to senate
07/08/2011DELIVERED TO GOVERNOR
07/20/2011SIGNED CHAP.219
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S05800 Memo:

Memo not available
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S05800 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          5800
 
                               2011-2012 Regular Sessions
 
                    IN SENATE
 
                                      June 17, 2011
                                       ___________
 
        Introduced by Sen. SEWARD -- (at request of the New York State Insurance
          Department)  -- read twice and ordered printed, and when printed to be
          committed to the Committee on Rules
 
        AN ACT to amend the insurance law and the public health law, in relation
          to implementation of the federal affordable care act in health  insur-
          ance policies and contracts

 
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
 
     1    Section 1. Subsection (b) of section 3105  of  the  insurance  law  is
     2  amended to read as follows:
     3    (b)(1)  No  misrepresentation shall avoid any contract of insurance or
     4  defeat recovery thereunder unless such misrepresentation  was  material.
     5  No  misrepresentation  shall  be deemed material unless knowledge by the
     6  insurer of the facts misrepresented would have led to a refusal  by  the
     7  insurer to make such contract.
     8    (2)  With  respect  to  a  policy  of  hospital, medical, surgical, or
     9  prescription drug expense insurance subject to  articles  thirty-two  or
    10  forty-three  of  this  chapter,  no  misrepresentation  shall  avoid any

    11  contract of insurance or defeat recovery thereunder unless the misrepre-
    12  sentation was also intentional.
    13    § 2. Subsection (a) of section 3216 of the insurance law, paragraph  4
    14  as  amended by section 65-d of part A of chapter 58 of the laws of 2007,
    15  and subparagraph (C) of paragraph 4 as added by chapter 240 of the  laws
    16  of 2009, is amended to read as follows:
    17    (a) In this section the term:
    18    (1) "Policy  of accident and health insurance" includes any individual
    19  policy or contract covering the kind or kinds of insurance described  in
    20  paragraph  three  of  subsection (a) of section one thousand one hundred
    21  thirteen of this chapter.
    22    (2) "Indemnity" means benefits promised.
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.

                                                                   LBD09858-05-1

        S. 5800                             2
 
     1    (3) "Family" may include [husband, wife] the policyholder's spouse, or
     2  dependent children, or any other person dependent upon the policyholder.
     3    (4) "Dependent children" (A) shall include any children under a speci-
     4  fied age which shall not exceed age nineteen except:
     5    (i) Any unmarried dependent child, regardless of age, who is incapable
     6  of self-sustaining employment by reason of mental illness, developmental
     7  disability,  or mental retardation as defined in the mental hygiene law,
     8  or physical handicap and who became so incapable prior  to  the  age  at
     9  which dependent coverage would otherwise terminate, shall be included in
    10  coverage subject to any pre-existing conditions limitation applicable to

    11  other dependents[.]; or
    12    (ii)  Any  unmarried  student at an accredited institution of learning
    13  may be considered a dependent child until attaining age  twenty-three[.]
    14  for  a  policy  other  than hospital, medical, surgical, or prescription
    15  drug expense insurance; or
    16    (iii) Any married or unmarried child shall be considered  a  dependent
    17  child until attaining age twenty-six without regard to financial depend-
    18  ence,  residency  with  the policyholder, student status, or employment,
    19  for a policy  of  hospital,  medical,  surgical,  or  prescription  drug
    20  expense insurance.
    21    (B)  may  include,  at  the option of the insurer, any unmarried child
    22  until attaining age  twenty-five  for  a  policy  other  than  hospital,

    23  medical, surgical, or prescription drug expense insurance.
    24    (C)  In  addition  to the requirements of subparagraphs (A) and (B) of
    25  this paragraph, every insurer issuing a policy of hospital, medical,  or
    26  surgical expense insurance pursuant to this section that provides cover-
    27  age  for dependent children must make available and, if requested by the
    28  policyholder, extend coverage under the policy  to  an  unmarried  child
    29  through  age  twenty-nine, without regard to financial dependence who is
    30  not insured by or eligible for coverage under  an  employer  [sponsored]
    31  health  benefit  plan  [covering them] as an employee or member, whether
    32  insured or self-insured, and who lives, works or  resides  in  New  York
    33  state  or  the  service area of the insurer. Such coverage shall be made

    34  available at the inception of all new policies [and at the  first  anni-
    35  versary  date  of a policy following the effective date of this subpara-
    36  graph]. Written notice of the availability of  such  coverage  shall  be
    37  delivered to the policyholder thirty days prior to the inception of such
    38  [group]  policy  [and  thirty  days  prior to the first anniversary date
    39  following the effective date of this subparagraph].
    40    § 3. Paragraph 9 of subsection (i) of section 3216  of  the  insurance
    41  law,  as added by chapter 705 of the laws of 1996, is amended to read as
    42  follows:
    43    (9)(A) Every policy  [which]  that  provides  coverage  for  inpatient
    44  hospital care shall also include coverage for services to treat an emer-

    45  gency condition in hospital facilities[. An]:
    46    (i) without the need for any prior authorization determination;
    47    (ii)  regardless  of  whether the health care provider furnishing such
    48  services is a participating provider with respect to such services;
    49    (iii) if the emergency services are provided  by  a  non-participating
    50  provider,  without imposing any administrative requirement or limitation
    51  on coverage that is more restrictive than the  requirements  or  limita-
    52  tions  that  apply  to  emergency  services  received from participating
    53  providers; and
    54    (iv) if the emergency services are  provided  by  a  non-participating
    55  provider,  the  cost-sharing  requirement  (expressed  as a copayment or

        S. 5800                             3
 
     1  coinsurance) shall be the same requirement  that  would  apply  if  such
     2  services were provided by a participating provider.
     3    (B)  Any requirements of section 2719A(b) of the Public Health Service
     4  Act, 42 U.S.C.  § 300gg19a(b) and regulations thereunder that exceed the
     5  requirements of this paragraph with respect  to  coverage  of  emergency
     6  services shall be applicable to every policy subject to this paragraph.
     7    (C)  For  purposes of this paragraph, an "emergency condition" means a
     8  medical or behavioral condition[, the onset of which  is  sudden,]  that
     9  manifests  itself  by  acute  symptoms of sufficient severity, including

    10  severe pain, such that a prudent layperson, possessing an average  know-
    11  ledge  of  medicine  and  health, could reasonably expect the absence of
    12  immediate medical attention to result in [(A)] (i) placing the health of
    13  the person afflicted with such condition in serious jeopardy, or in  the
    14  case  of  a  behavioral  condition  placing the health of such person or
    15  others in serious jeopardy[, or (B)]; (ii) serious  impairment  to  such
    16  person's bodily functions; [(C)] (iii) serious dysfunction of any bodily
    17  organ  or  part  of  such person; [or (D)] (iv) serious disfigurement of
    18  such person; or (v) a condition described in clause (i), (ii)  or  (iii)
    19  of section 1867(e)(1)(A) of the Social Security Act.

    20    (D)  For  purposes of this paragraph, "emergency services" means, with
    21  respect to an emergency condition: (i) a medical  screening  examination
    22  as  required  under section 1867 of the Social Security Act, 42 U.S.C. §
    23  1395dd, which is within the capability of the emergency department of  a
    24  hospital,  including ancillary services routinely available to the emer-
    25  gency department to evaluate such emergency medical condition; and  (ii)
    26  within  the  capabilities  of  the staff and facilities available at the
    27  hospital, such further medical examination and treatment as are required
    28  under section 1867 of the Social Security Act, 42 U.S.C.   § 1395dd,  to
    29  stabilize the patient.

    30    (E) For purposes of this paragraph, "to stabilize" means, with respect
    31  to  an  emergency  condition,  to  provide such medical treatment of the
    32  condition as may be necessary to assure, within reasonable medical prob-
    33  ability, that no material deterioration of the condition  is  likely  to
    34  result  from or occur during the transfer of the insured from a facility
    35  or to deliver a newborn child (including the placenta).
    36    § 4. Paragraph 11 of subsection (i) of section 3216 of  the  insurance
    37  law,  as added by chapter 417 of the laws of 1989, is amended to read as
    38  follows:
    39    (11) (A) Every policy [which] that  provides  coverage  for  hospital,
    40  surgical  or  medical  care  shall  provide  the  following coverage for
    41  mammography screening for occult breast cancer:

    42    (i) upon the recommendation of a physician, a mammogram at any age for
    43  covered persons having a prior history of breast cancer or [whose mother
    44  or sister has] who have a first degree relative with a prior history  of
    45  breast cancer;
    46    (ii)  a single baseline mammogram for covered persons aged thirty-five
    47  through thirty-nine, inclusive; and
    48    (iii) [a mammogram every two years, or more frequently upon the recom-
    49  mendation of a physician, for covered persons aged forty through  forty-
    50  nine, inclusive; and
    51    (iv)]  an  annual mammogram for covered persons aged [fifty] forty and
    52  older.
    53    (B) Such coverage required pursuant to subparagraph (A) or (C) of this

    54  paragraph may be subject to annual deductibles and coinsurance as may be
    55  deemed appropriate by the superintendent  and  as  are  consistent  with
    56  those established for other benefits within a given policy.

        S. 5800                             4
 
     1    (C)  For  purposes  of  subparagraphs  (A)  and (B) of this paragraph,
     2  mammography screening means an X-ray examination  of  the  breast  using
     3  dedicated  equipment,  including X-ray tube, filter, compression device,
     4  screens, films and cassettes, with an average glandular  radiation  dose
     5  less than 0.5 rem per view per breast.
     6    (D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph,
     7  every policy that provides coverage for hospital,  surgical  or  medical

     8  care,  except  for a grandfathered health plan under subparagraph (E) of
     9  this paragraph, shall provide coverage  for  the  following  mammography
    10  screening  services,  and  such  coverage shall not be subject to annual
    11  deductibles or coinsurance:
    12    (i) evidence-based items or services  for  mammography  that  have  in
    13  effect  a  rating  of  'A'  or 'B' in the current recommendations of the
    14  United States preventive services task force; and
    15    (ii) with respect  to  women,  such  additional  preventive  care  and
    16  screenings  for  mammography  not described in item (i) of this subpara-
    17  graph and as provided for in comprehensive guidelines supported  by  the
    18  health resources and services administration.

    19    (E)  For purposes of this paragraph, "grandfathered health plan" means
    20  coverage provided by an insurer in which an individual was  enrolled  on
    21  March  twenty-third,  two thousand ten for as long as the coverage main-
    22  tains grandfathered status in accordance with  section  1251(e)  of  the
    23  Affordable Care Act, 42 U.S.C. § 18011(e).
    24    §  5.  Paragraph 15 of subsection (i) of section 3216 of the insurance
    25  law, as amended by chapter 43 of the laws of 1993, is amended to read as
    26  follows:
    27    (15) (A) Every policy [which]  that  provides  hospital,  surgical  or
    28  medical  care coverage or provides reimbursement for laboratory tests or
    29  reimbursement for diagnostic X-ray services shall provide  coverage  for
    30  an  annual  cervical  cytology  screening  for  cervical  cancer and its

    31  precursor states for women aged eighteen and older.
    32    (B) For purposes of subparagraphs  (A)  and  (C)  of  this  paragraph,
    33  cervical  cytology screening shall include an annual pelvic examination,
    34  collection and preparation of a Pap smear, and laboratory and diagnostic
    35  services provided in connection with examining and  evaluating  the  Pap
    36  smear.
    37    (C) Such coverage required pursuant to subparagraph (A) or (B) of this
    38  paragraph may be subject to annual deductibles and coinsurance as may be
    39  deemed  appropriate  by  the  superintendent  and as are consistent with
    40  those established for other benefits within a given policy.
    41    (D) In addition to subparagraph (A), (B) or  (C)  of  this  paragraph,
    42  every  policy that provides hospital, surgical or medical care coverage,

    43  except for a grandfathered health plan under subparagraph  (E)  of  this
    44  paragraph,  shall  provide  coverage for the following cervical cytology
    45  screening services, and such coverage shall not  be  subject  to  annual
    46  deductibles or coinsurance:
    47    (i)  evidence-based  items or services for cervical cytology that have
    48  in effect a rating of 'A' or 'B' in the current recommendations  of  the
    49  United States preventive services task force; and
    50    (ii)  with  respect  to  women,  such  additional  preventive care and
    51  screenings for cervical cytology not  described  in  item  (i)  of  this
    52  subparagraph  and  as provided for in comprehensive guidelines supported
    53  by the health resources and services administration.

    54    (E) For purposes of this paragraph, "grandfathered health plan"  means
    55  coverage  provided  by an insurer in which an individual was enrolled on
    56  March twenty-third, two thousand ten for as long as the  coverage  main-

        S. 5800                             5
 
     1  tains  grandfathered  status  in  accordance with section 1251(e) of the
     2  Affordable Care Act, 42 U.S.C. § 18011(e).
     3    §  6.  Paragraph 17 of subsection (i) of section 3216 of the insurance
     4  law, as added by chapter 728 of the laws of 1993, is amended to read  as
     5  follows:
     6    (17)  (A) Every policy [which] that provides medical, major-medical or
     7  similar comprehensive-type  coverage  shall  provide  coverage  for  the
     8  provision of preventive and primary care services.

     9    (B)  For  the purposes of subparagraphs (A), (C) and (D) of this para-
    10  graph, preventive and primary care services means the following services
    11  rendered to a [dependent] covered child of an insured from the  date  of
    12  birth through the attainment of nineteen years;
    13    (i)  an  initial  hospital check-up and well-child visits scheduled in
    14  accordance with the prevailing clinical standards of a national  associ-
    15  ation  of  pediatric physicians designated by the commissioner of health
    16  (except for any standard that would limit  the  specialty  or  forum  of
    17  licensure  of  the  practitioner  providing  the  service other than the
    18  limits under state law). Coverage for such services  rendered  shall  be
    19  provided  only to the extent that such services are provided by or under
    20  the supervision of a physician, or  other  professional  licensed  under

    21  article  one  hundred  thirty-nine  of  the education law whose scope of
    22  practice pursuant to such law includes  the  authority  to  provide  the
    23  specified  services.  Coverage  shall  be  provided  for  such  services
    24  rendered in a hospital, as defined in section twenty-eight  hundred  one
    25  of  the  public  health  law,  or  in  an office of a physician or other
    26  professional licensed under  article  one  hundred  thirty-nine  of  the
    27  education  law whose scope of practice pursuant to such law includes the
    28  authority to provide the specified services;
    29    (ii) at each visit, services in accordance with the  prevailing  clin-
    30  ical  standards  of  such  designated  association,  including a medical
    31  history, a  complete  physical  examination,  developmental  assessment,
    32  anticipatory  guidance,  appropriate  immunizations and laboratory tests

    33  which tests are ordered at the time of the visit and  performed  in  the
    34  practitioner's  office, as authorized by law, or in a clinical laborato-
    35  ry; and
    36    (iii) necessary immunizations, as determined by the superintendent  in
    37  consultation  with  the  commissioner  of health, consisting of at least
    38  adequate dosages of  vaccine  against  diphtheria,  pertussis,  tetanus,
    39  polio,  measles, rubella, mumps, haemophilus influenzae type b and hepa-
    40  titis b, which meet the standards approved by the United  States  public
    41  health service for such biological products.
    42    (C) Such coverage required pursuant to subparagraph (A) or (B) of this
    43  paragraph shall not be subject to annual deductibles [and/or] or coinsu-
    44  rance.

    45    (D) Such coverage required pursuant to subparagraph (A) or (B) of this
    46  paragraph  shall not restrict or eliminate existing coverage provided by
    47  the policy.
    48    (E) In addition to subparagraph (A), (B), (C) or  (D)  of  this  para-
    49  graph,  every  policy  that  provides hospital, surgical or medical care
    50  coverage, except for a grandfathered health plan under subparagraph  (F)
    51  of  this  paragraph, shall provide coverage for the following preventive
    52  care and screenings for insureds, and such coverage shall not be subject
    53  to annual deductibles or coinsurance:
    54    (i) evidence-based items or services for preventive care  and  screen-
    55  ings that have in effect a rating of 'A' or 'B' in the current recommen-

    56  dations of the United States preventive services task force;

        S. 5800                             6
 
     1    (ii) immunizations that have in effect a recommendation from the advi-
     2  sory  committee  on  immunization  practices  of the centers for disease
     3  control and prevention with respect to the individual involved;
     4    (iii)  with  respect  to  children, including infants and adolescents,
     5  evidence-informed preventive care and screenings provided for in compre-
     6  hensive guidelines supported by the health resources and services admin-
     7  istration; and
     8    (iv) with respect  to  women,  such  additional  preventive  care  and
     9  screenings  not  described  in  item  (i)  of  this  subparagraph and as

    10  provided  for  in  comprehensive  guidelines  supported  by  the  health
    11  resources and services administration.
    12    (F)  For purposes of this paragraph, "grandfathered health plan" means
    13  coverage provided by an insurer in which an individual was  enrolled  on
    14  March  twenty-third,  two thousand ten for as long as the coverage main-
    15  tains grandfathered status in accordance with  section  1251(e)  of  the
    16  Affordable Care Act, 42 U.S.C. § 18011(e).
    17    §  7.  Subparagraph  (E)  of paragraph 24 of subsection (i) of section
    18  3216 of the insurance law, as added by chapter 506 of the laws of  2001,
    19  is amended to read as follows:
    20    (E) As used in this paragraph:
    21    (i)  "Prehospital  emergency medical services" means the prompt evalu-

    22  ation and treatment of an emergency medical condition,  and/or  non-air-
    23  borne  transportation  of  the  patient to a hospital, provided however,
    24  where the patient utilizes non-air-borne emergency transportation pursu-
    25  ant to this paragraph, reimbursement [will] shall be based on whether  a
    26  prudent  layperson,  possessing  an  average  knowledge  of medicine and
    27  health, could reasonably expect the absence of  such  transportation  to
    28  result in [(1)] (I) placing the health of the person afflicted with such
    29  condition  in serious jeopardy, or in the case of a behavioral condition
    30  placing the health of such person or others in serious  jeopardy;  [(2)]
    31  (II)  serious  impairment to such person's bodily functions; [(3)] (III)

    32  serious dysfunction of any bodily organ or part of such person; [or (4)]
    33  (IV) serious disfigurement of such person; or (V) a condition  described
    34  in  clause  (i),  (ii),  or (iii) of section 1867(e)(1)(A) of the Social
    35  Security Act.
    36    (ii) "Emergency condition" means a medical or  behavioral  condition[,
    37  the  onset  of which is sudden,] that manifests itself by acute symptoms
    38  of sufficient severity, including  severe  pain,  such  that  a  prudent
    39  layperson, possessing an average knowledge of medicine and health, could
    40  reasonably  expect  the absence of immediate medical attention to result
    41  in [(1)] (I) placing the health of the person afflicted with such condi-
    42  tion in serious jeopardy, or in the case of a behavioral condition plac-

    43  ing the health of such person or others in serious jeopardy; [(2)]  (II)
    44  serious  impairment to such person's bodily functions; [(3)] (III) seri-
    45  ous dysfunction of any bodily organ or part of  such  person;  [or  (4)]
    46  (IV)  serious disfigurement of such person; or (V) a condition described
    47  in clause (i), (ii), or (iii) of section  1867(e)(1)(A)  of  the  Social
    48  Security Act.
    49    §  8.  Section 3217-c of the insurance law, as added by chapter 554 of
    50  the laws of 2002, is amended to read as follows:
    51    § 3217-c. Primary and preventive obstetric and gynecologic care.   (a)
    52  No  insurer subject to this article shall by contract, written policy or
    53  procedure limit a female insured's direct access to primary and  preven-

    54  tive  obstetric and gynecologic services, including annual examinations,
    55  care resulting from such annual examinations,  and  treatment  of  acute
    56  gynecologic  conditions,  from  a qualified provider of such services of

        S. 5800                             7
 
     1  her choice from within the plan [to less than two examinations  annually
     2  for  such  services]  or  [to]  for any care related to a pregnancy[. In
     3  addition, no insurer subject to this article shall by contract,  written
     4  policy  or  procedure  limit  direct  access  to  primary and preventive
     5  obstetric and gynecologic services required as a result of  such  annual
     6  examinations or as a result of an acute gynecologic condition], provided

     7  that:  (1) such qualified provider discusses such services and treatment
     8  plan with the insured's primary care practitioner in accordance with the
     9  requirements of the insurer; and (2) such qualified provider  agrees  to
    10  adhere  to the insurer's policies and procedures, including any applica-
    11  ble procedures regarding referrals and obtaining prior authorization for
    12  services other than obstetric and gynecologic services rendered by  such
    13  qualified  provider, and agrees to provide services pursuant to a treat-
    14  ment plan (if any) approved by the insurer.
    15    (b) An insurer shall treat the provision of obstetric and  gynecologic
    16  care,  and  the  ordering of related obstetric and gynecologic items and

    17  services, pursuant to the direct access described in subsection  (a)  of
    18  this  section by a participating qualified provider of such services, as
    19  the authorization of the primary care provider.
    20    (c) It shall be the duty of the administrative officer or other person
    21  in charge of each insurer subject to the provisions of this  article  to
    22  advise  each  female  insured,  in  writing,  of  the provisions of this
    23  section.
    24    § 9. The insurance law is amended by adding a new  section  3217-e  to
    25  read as follows:
    26    §  3217-e.  Choice of health care provider. An insurer that is subject
    27  to this article and requires or provides for designation by  an  insured
    28  of  a  participating  primary  care provider shall permit the insured to

    29  designate any participating primary care provider who  is  available  to
    30  accept  such  individual,  and  in the case of a child, shall permit the
    31  insured  to  designate  a  physician  (allopathic  or  osteopathic)  who
    32  specializes  in  pediatrics as the child's primary care provider if such
    33  provider participates in the network of the insurer.
    34    § 10. The insurance law is amended by adding a new section  3217-f  to
    35  read as follows:
    36    §  3217-f.  Prohibition on lifetime and annual limits.  (a) An insurer
    37  shall not establish a lifetime limit on the dollar amount  of  essential
    38  health  benefits  in an individual, group or blanket policy of hospital,
    39  medical, surgical or prescription drug expense insurance.

    40    (b) An insurer shall not establish  an  annual  limit  on  the  dollar
    41  amount  of  essential health benefits in an individual, group or blanket
    42  policy of hospital,  medical,  surgical  or  prescription  drug  expense
    43  insurance for policy years beginning on and after January one, two thou-
    44  sand fourteen.
    45    (c)  For  policy  years  beginning  prior to January one, two thousand
    46  fourteen, an insurer may  establish  restricted  annual  limits  on  the
    47  dollar  amount  of essential health benefits in an individual, group, or
    48  blanket policy of  hospital,  medical,  surgical  or  prescription  drug
    49  expense  insurance  consistent  with  section  2711 of the Public Health
    50  Service Act, 42 U.S.C.  § 300gg-11 or any regulations thereunder.

    51    (d) The requirements of subsections (b) and (c) of this section  shall
    52  not be applicable to an individual policy that is a grandfathered health
    53  plan.  For  purposes  of this section, "grandfathered health plan" means
    54  coverage provided by an insurer in which an individual was  enrolled  on
    55  March  twenty-third,  two thousand ten for as long as the coverage main-

        S. 5800                             8
 
     1  tains grandfathered status in accordance with  section  1251(e)  of  the
     2  Affordable Care Act, 42 U.S.C. § 18011(e).
     3    (e)  For  purposes  of this section, "essential health benefits" shall
     4  have the meaning ascribed by section 1302(b) of the Affordable Care Act,
     5  42 U.S.C. § 18022(b).

     6    § 11. Subsection (e) of section 3221 of the insurance law  is  amended
     7  by adding a new paragraph 12 to read as follows:
     8    (12)  For  purposes  of  this  subsection,  the term "dependent" shall
     9  include a child as described in subsection (f) of section four  thousand
    10  two hundred thirty-five of this chapter.
    11    §  12.  Subsection (h) of section 3221 of the insurance law is amended
    12  by adding a new paragraph 5 to read as follows:
    13    (5) For the purpose of determining the benefits payable for a  covered
    14  person,  an  insurer  shall  not  impose  a lifetime limit on the dollar
    15  amount of benefits that are defined as essential health benefits  pursu-
    16  ant to section 1302(b) of the Affordable Care Act, 42 U.S.C. § 18022(b).

    17    §  13.  Paragraph 4 of subsection (k) of section 3221 of the insurance
    18  law, as added by chapter 705 of the laws of 1996, is amended to read  as
    19  follows:
    20    (4)  (A)  Every  group policy delivered or issued for delivery in this
    21  state [which] that provides coverage for inpatient hospital  care  shall
    22  include  coverage  for services to treat an emergency condition provided
    23  in hospital facilities, except that this provision shall not apply to  a
    24  policy  which  [cover] covers persons employed in more than one state or
    25  the benefit structure of which was the subject of collective  bargaining
    26  affecting  persons  who  are  employed in more than one state unless the
    27  policy otherwise provides coverage for services to  treat  an  emergency
    28  condition provided in hospital facilities:

    29    (i) without the need for any prior authorization determination;
    30    (ii)  regardless  of  whether the health care provider furnishing such
    31  services is a participating provider with respect to such services;
    32    (iii) if the emergency services are provided  by  a  non-participating
    33  provider,  without imposing any administrative requirement or limitation
    34  on coverage that is more restrictive than the  requirements  or  limita-
    35  tions  that  apply  to  emergency  services  received from participating
    36  providers; and
    37    (iv) if the emergency services are  provided  by  a  non-participating
    38  provider,  the  cost-sharing  requirement  (expressed  as a copayment or
    39  coinsurance) shall be the same requirement  that  would  apply  if  such

    40  services were provided by a participating provider.
    41    (B)  Any requirements of section 2719A(b) of the Public Health Service
    42  Act, 42 U.S.C.  § 300gg19a(b) and regulations thereunder that exceed the
    43  requirements of this paragraph with respect  to  coverage  of  emergency
    44  services shall be applicable to every policy subject to this paragraph.
    45    (C)  In  this  paragraph,  an "emergency condition" means a medical or
    46  behavioral condition[, the onset of which  is  sudden,]  that  manifests
    47  itself  by acute symptoms of sufficient severity, including severe pain,
    48  such that a prudent layperson, possessing an average knowledge of  medi-
    49  cine  and  health,  could  reasonably  expect  the  absence of immediate
    50  medical attention to result in (i) placing  the  health  of  the  person

    51  afflicted  with  such condition in serious jeopardy, or in the case of a
    52  behavioral condition placing the health of  such  person  or  others  in
    53  serious  jeopardy[, or]; (ii) serious impairment to such person's bodily
    54  functions; (iii) serious dysfunction of any bodily organ or part of such
    55  person; [or] (iv) serious disfigurement of such person; or (v) a  condi-

        S. 5800                             9
 
     1  tion  described in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of
     2  the Social Security Act.
     3    (D)  In this paragraph, "emergency services" means, with respect to an
     4  emergency condition:  (i) a medical screening  examination  as  required
     5  under section 1867 of the Social Security Act, 42 U.S.C. § 1395dd, which

     6  is  within  the  capability  of  the emergency department of a hospital,
     7  including  ancillary  services  routinely  available  to  the  emergency
     8  department to evaluate such emergency medical condition: and (ii) within
     9  the  capabilities of the staff and facilities available at the hospital,
    10  such further medical examination and treatment  as  are  required  under
    11  section  1867  of the Social Security Act, 42 U.S.C. § 1395dd, to stabi-
    12  lize the patient.
    13    (E) In this paragraph, "to stabilize" means, with respect to an  emer-
    14  gency  condition,  to provide such medical treatment of the condition as
    15  may be necessary to assure, within reasonable medical probability,  that
    16  no  material  deterioration of the condition is likely to result from or

    17  occur during the transfer of the insured from a facility or to deliver a
    18  newborn child (including the placenta).
    19    § 14. Paragraph 13 of subsection (k) of section 3221 of the  insurance
    20  law,  as added by chapter 554 of the laws of 2002, is amended to read as
    21  follows:
    22    (13) Every group or blanket policy delivered or issued for delivery in
    23  this state [which] that provides major  medical  or  similar  comprehen-
    24  sive-type  coverage shall provide such coverage for bone mineral density
    25  measurements or tests, and if such contract otherwise includes  coverage
    26  for  prescription  drugs, drugs and devices approved by the federal food
    27  and drug administration or generic equivalents as approved  substitutes.
    28  In  determining  appropriate coverage provided by subparagraphs (A), (B)

    29  and (C) of this paragraph, the insurer or health  maintenance  organiza-
    30  tion  shall  adopt  standards  [which]  that include the criteria of the
    31  federal [medicare] Medicare program and the  criteria  of  the  national
    32  institutes  of  health  for the detection of osteoporosis, provided that
    33  such coverage shall be further determined as follows:
    34    (A) for purposes of subparagraphs (B) and (C) of this paragraph,  bone
    35  mineral  density  measurements or tests, drugs and devices shall include
    36  those covered under the federal Medicare program as  well  as  those  in
    37  accordance  with  the  criteria  of  the  national institutes of health,
    38  including, as consistent with such criteria, dual-energy  x-ray  absorp-
    39  tiometry.
    40    (B)  for purposes of subparagraphs (A) and (C) of this paragraph, bone

    41  mineral density measurements  or  tests,  drugs  and  devices  shall  be
    42  covered  for individuals meeting the criteria under the federal Medicare
    43  program or the criteria of the national institutes of  health;  provided
    44  that,  to the extent consistent with such criteria, individuals qualify-
    45  ing for coverage shall at a minimum, include individuals:
    46    (i) previously diagnosed as having osteoporosis  or  having  a  family
    47  history of osteoporosis; or
    48    (ii)  with  symptoms  or conditions indicative of the presence, or the
    49  significant risk, of osteoporosis; or
    50    (iii) on a prescribed drug regimen posing a significant risk of osteo-
    51  porosis; or
    52    (iv) with lifestyle factors to such a degree as posing  a  significant
    53  risk of osteoporosis; or
    54    (v)  with  such age, gender and/or other physiological characteristics
    55  which pose a significant risk for osteoporosis.

        S. 5800                            10
 
     1    (C) Such coverage required pursuant to subparagraph (A) or (B) of this
     2  paragraph may be subject to annual deductibles and coinsurance as may be
     3  deemed appropriate by the superintendent  and  as  are  consistent  with
     4  those established for other benefits within a given policy.
     5    (D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph,
     6  every group or  blanket  policy  that  provides  hospital,  surgical  or
     7  medical  care  coverage,  except  for  a grandfathered health plan under
     8  subparagraph (E) of this  paragraph,  shall  provide  coverage  for  the
     9  following  items  or services for bone mineral density and such coverage
    10  shall not be subject to annual deductibles or coinsurance:

    11    (i) evidence-based items or services for  bone  mineral  density  that
    12  have  in effect a rating of 'A' or 'B' in the current recommendations of
    13  the United States preventive services task force; and
    14    (ii) with respect  to  women,  such  additional  preventive  care  and
    15  screenings  for  bone  mineral density not described in item (i) of this
    16  subparagraph and as provided for in comprehensive  guidelines  supported
    17  by the health resources and services administration.
    18    (E)  For purposes of this paragraph, "grandfathered health plan" means
    19  coverage provided by an insurer in which an individual was  enrolled  on
    20  March  twenty-third,  two thousand ten for as long as the coverage main-

    21  tains grandfathered status in accordance with  section  1251(e)  of  the
    22  Affordable Care Act, 42 U.S.C. § 18011(e).
    23    §  15.  Paragraph 8 of subsection (l) of section 3221 of the insurance
    24  law, as amended by chapter 728 of the laws of 1993, is amended  to  read
    25  as follows:
    26    (8)  (A)  Every  insurer  issuing  a group policy for delivery in this
    27  state [which] that provides medical, major-medical or similar comprehen-
    28  sive-type coverage [must] shall provide coverage for  the  provision  of
    29  preventive and primary care services.
    30    (B)  In  subparagraphs  (A), (C) and (D) of this paragraph, preventive
    31  and primary care services means the following  services  rendered  to  a
    32  [dependent]  covered  child of an insured from the date of birth through

    33  the attainment of nineteen years of age:
    34    (i) an initial hospital check-up and well-child  visits  scheduled  in
    35  accordance  with the prevailing clinical standards of a national associ-
    36  ation of pediatric physicians designated by the commissioner  of  health
    37  (except  for  any  standard  that  would limit the specialty or forum of
    38  licensure of the practitioner  providing  the  service  other  than  the
    39  limits  under  state  law). Coverage for such services rendered shall be
    40  provided only to the extent that such services are provided by or  under
    41  the  supervision  of  a  physician, or other professional licensed under
    42  article one hundred thirty-nine of the  education  law  whose  scope  of
    43  practice  pursuant  to  such  law  includes the authority to provide the
    44  specified  services.  Coverage  shall  be  provided  for  such  services

    45  rendered  in  a hospital, as defined in section twenty-eight hundred one
    46  of the public health law, or in  an  office  of  a  physician  or  other
    47  professional  licensed  under  article  one  hundred  thirty-nine of the
    48  education law whose scope of practice pursuant to such law includes  the
    49  authority to provide the specified services;
    50    (ii)  at  each visit, services in accordance with the prevailing clin-
    51  ical standards of  such  designated  association,  including  a  medical
    52  history,  a  complete  physical  examination,  developmental assessment,
    53  anticipatory guidance, appropriate immunizations  and  laboratory  tests
    54  which  tests  are  ordered at the time of the visit and performed in the
    55  practitioner's office, as authorized by law, or in a clinical  laborato-
    56  ry; and

        S. 5800                            11
 

     1    (iii)  necessary immunizations, as determined by the superintendent in
     2  consultation with the commissioner of health,  consisting  of  at  least
     3  adequate  dosages  of  vaccine  against  diphtheria, pertussis, tetanus,
     4  polio, measles, rubella, mumps, haemophilus influenzae type b and  hepa-
     5  titis  b,  which meet the standards approved by the United States public
     6  health service for such biological products.
     7    (C) Such coverage required pursuant to subparagraph (A) or (B) of this
     8  paragraph shall not be subject to annual deductibles [and/or] or coinsu-
     9  rance.
    10    (D) Such coverage required pursuant to subparagraph (A) or (B) of this
    11  paragraph shall not restrict or eliminate existing coverage provided  by
    12  the policy.

    13    (E)  In  addition  to  subparagraph (A), (B), (C) or (D) of this para-
    14  graph, every group policy that provides hospital,  surgical  or  medical
    15  care coverage, except for a grandfathered health plan under subparagraph
    16  (G)  of this paragraph, shall provide coverage for the following preven-
    17  tive care and screenings for insureds, and such coverage  shall  not  be
    18  subject to annual deductibles or coinsurance:
    19    (i)  evidence-based  items or services for preventive care and screen-
    20  ings that have in effect a rating of 'A' or 'B' in the current recommen-
    21  dations of the United States preventive services task force;
    22    (ii) immunizations that have in effect a recommendation from the advi-

    23  sory committee on immunization practices  of  the  centers  for  disease
    24  control and prevention with respect to the individual involved;
    25    (iii)  with  respect  to  children, including infants and adolescents,
    26  evidence-informed preventive care and screenings provided for in compre-
    27  hensive guidelines supported by the health resources and services admin-
    28  istration; and
    29    (iv) with respect  to  women,  such  additional  preventive  care  and
    30  screenings  not  described  in  item  (i)  of  this  subparagraph and as
    31  provided  for  in  comprehensive  guidelines  supported  by  the  health
    32  resources and services administration.
    33    (F)  The  requirements of this paragraph shall also be applicable to a

    34  blanket policy of hospital, medical or surgical expense insurance cover-
    35  ing  students  pursuant  to  subparagraph  (C)  of  paragraph  three  of
    36  subsection (a) of section four thousand two hundred thirty-seven of this
    37  chapter.
    38    (G)  For purposes of this paragraph, "grandfathered health plan" means
    39  coverage provided by an insurer in which an individual was  enrolled  on
    40  March  twenty-third,  two thousand ten for as long as the coverage main-
    41  tains grandfathered status in accordance with  section  1251(e)  of  the
    42  Affordable Care Act, 42 U.S.C. § 18011(e).
    43    §  16. Paragraph 11 of subsection (l) of section 3221 of the insurance
    44  law, as amended by chapter 554 of the laws of 2002, is amended  to  read
    45  as follows:

    46    (11) (A) Every insurer delivering a group or blanket policy or issuing
    47  a  group  or  blanket  policy  for  delivery  in this state [which] that
    48  provides coverage for hospital, surgical or medical care  shall  provide
    49  the  following  coverage  for  mammography  screening  for occult breast
    50  cancer:
    51    (i) upon the recommendation of a physician, a mammogram at any age for
    52  covered persons having a prior history of breast cancer or  who  have  a
    53  first degree relative with a prior history of breast cancer;
    54    (ii)  a single baseline mammogram for covered persons aged thirty-five
    55  through thirty-nine, inclusive; and
    56    (iii) an annual mammogram for covered persons aged forty and older.

        S. 5800                            12
 
     1    (B) Such coverage required pursuant to subparagraph (A) or (C) of this

     2  paragraph may be subject to annual deductibles and coinsurance as may be
     3  deemed appropriate by the superintendent  and  as  are  consistent  with
     4  those established for other benefits within a given policy.
     5    (C)  For  purposes  of  subparagraphs  (A)  and (B) of this paragraph,
     6  mammography screening means an X-ray examination  of  the  breast  using
     7  dedicated  equipment,  including X-ray tube, filter, compression device,
     8  screens, films and cassettes, with an average glandular  radiation  dose
     9  less than 0.5 rem per view per breast.
    10    (D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph,
    11  every group or blanket  policy  that  provides  coverage  for  hospital,
    12  surgical  or  medical care, except for a grandfathered health plan under

    13  subparagraph (E) of this  paragraph,  shall  provide  coverage  for  the
    14  following mammography screening services, and such coverage shall not be
    15  subject to annual deductibles or coinsurance:
    16    (i)  evidence-based  items  or  services  for mammography that have in
    17  effect a rating of 'A' or 'B' in  the  current  recommendations  of  the
    18  United States preventive services task force; and
    19    (ii)  with  respect  to  women,  such  additional  preventive care and
    20  screenings for mammography not described in item (i)  of  this  subpara-
    21  graph  and  as provided for in comprehensive guidelines supported by the
    22  health resources and services administration.
    23    (E) For purposes of this paragraph, "grandfathered health plan"  means

    24  coverage  provided  by an insurer in which an individual was enrolled on
    25  March twenty-third, two thousand ten for as long as the  coverage  main-
    26  tains  grandfathered  status  in  accordance with section 1251(e) of the
    27  Affordable Care Act, 42 U.S.C. § 18011(e).
    28    § 17. Paragraph 14 of subsection (l) of section 3221 of the  insurance
    29  law,  as  amended by chapter 554 of the laws of 2002, is amended to read
    30  as follows:
    31    (14) (A) Every group or blanket policy delivered or issued for  deliv-
    32  ery  in  this  state [which] that provides hospital, surgical or medical
    33  coverage shall provide coverage for an annual cervical cytology  screen-
    34  ing for cervical cancer and its precursor states for women aged eighteen
    35  and older.

    36    (B)  For  purposes  of  subparagraphs  (A)  and (C) of this paragraph,
    37  cervical cytology screening shall include an annual pelvic  examination,
    38  collection and preparation of a Pap smear, and laboratory and diagnostic
    39  services  provided  in  connection with examining and evaluating the Pap
    40  smear.
    41    (C) Such coverage required pursuant to subparagraph (A) or (B) of this
    42  paragraph may be subject to annual deductibles and coinsurance as may be
    43  deemed appropriate by the superintendent  and  as  are  consistent  with
    44  those established for other benefits within a given policy.
    45    (D)  In  addition  to  subparagraph (A), (B) or (C) of this paragraph,
    46  every group or  blanket  policy  that  provides  hospital,  surgical  or
    47  medical  coverage, except for a grandfathered health plan under subpara-

    48  graph (E) of this paragraph, shall provide coverage  for  the  following
    49  cervical  cytology  screening  services,  and such coverage shall not be
    50  subject to annual deductibles or coinsurance:
    51    (i) evidence-based items or services for cervical cytology  that  have
    52  in  effect  a rating of 'A' or 'B' in the current recommendations of the
    53  United States preventive services task force; and
    54    (ii) with respect  to  women,  such  additional  preventive  care  and
    55  screenings  for  cervical  cytology  not  described  in item (i) of this

        S. 5800                            13
 
     1  subparagraph and as provided for in comprehensive  guidelines  supported
     2  by the health resources and services administration.

     3    (E)  For purposes of this paragraph, "grandfathered health plan" means
     4  coverage provided by an insurer in which an individual was  enrolled  on
     5  March  twenty-third,  two thousand ten for as long as the coverage main-
     6  tains grandfathered status in accordance with  section  1251(e)  of  the
     7  Affordable Care Act, 42 U.S.C. § 18011(e).
     8    §  18.  Subparagraph  (E) of paragraph 15 of subsection (l) of section
     9  3221 of the insurance law, as added by chapter 506 of the laws of  2001,
    10  is amended to read as follows:
    11    (E) As used in this paragraph:
    12    (i)  "Prehospital  emergency medical services" means the prompt evalu-
    13  ation and treatment of an emergency medical condition,  and/or  non-air-
    14  borne  transportation  of  the  patient to a hospital, provided however,

    15  where the patient utilizes non-air-borne emergency transportation pursu-
    16  ant to this paragraph, reimbursement [will] shall be based on whether  a
    17  prudent  layperson,  possessing  an  average  knowledge  of medicine and
    18  health, could reasonably expect the absence of  such  transportation  to
    19  result  in [(1)] (I) placing the health of the person affected with such
    20  condition in serious jeopardy, or in the case of a behavioral  condition
    21  placing  the  health of such person or others in serious jeopardy; [(2)]
    22  (II) serious impairment to such person's bodily functions;  [(3)]  (III)
    23  serious dysfunction of any bodily organ or part of such person; [or (4)]
    24  (IV)  serious disfigurement of such person; or (V) a condition described

    25  in clause (i), (ii) or (iii) of  section  1867(e)(1)(A)  of  the  Social
    26  Security Act.
    27    (ii)  "Emergency  condition" means a medical or behavioral condition[,
    28  the onset of which is sudden,] that manifests itself by  acute  symptoms
    29  of  sufficient  severity,  including  severe  pain,  such that a prudent
    30  layperson, possessing an average knowledge of medicine and health, could
    31  reasonably expect the absence of immediate medical attention  to  result
    32  in [(1)] (I) placing the health of the person afflicted with such condi-
    33  tion in serious jeopardy, or in the case of a behavioral condition plac-
    34  ing  the health of such person or others in serious jeopardy; [(2)] (II)
    35  serious impairment to such person's bodily functions; ([3)] (III)  seri-

    36  ous  dysfunction  of  any  bodily organ or part of such person; [or (4)]
    37  (IV) serious disfigurement of such person; or (V) a condition  described
    38  in  clause  (i),  (ii)  or  (iii) of section 1867(e)(1)(A) of the Social
    39  Security Act.
    40    § 19. Subsection (m) of section 3221 of the insurance law  is  amended
    41  by adding a new paragraph 8 to read as follows:
    42    (8)  For  purposes  of  this  subsection,  the  term "dependent" shall
    43  include a child as described in subsection (f) of section four  thousand
    44  two hundred thirty-five of this chapter.
    45    §  20.  Subsection (p) of section 3221 of the insurance law is amended
    46  by adding a new paragraph 6 to read as follows:
    47    (6) For purposes  of  this  subsection,  the  term  "dependent"  shall

    48  include  a child as described in subsection (f) of section four thousand
    49  two hundred thirty-five of this chapter.
    50    § 21. Subsection (q) of section 3221 of the insurance law  is  amended
    51  by adding a new paragraph 7 to read as follows:
    52    (7)  For  purposes  of  this  subsection,  the  term "dependent" shall
    53  include a child as described in subsection (f) of section four  thousand
    54  two hundred thirty-five of this chapter.

        S. 5800                            14
 
     1    §  22.  Paragraphs  1  and  2 of subsection (r) of section 3221 of the
     2  insurance law, as added by chapter 240 of the laws of 2009, are  amended
     3  to read as follows:
     4    (1)  As  used in this subsection, ["dependent child"] "child" means an

     5  unmarried child through age twenty-nine of an employee or member insured
     6  under a group policy of hospital, medical or surgical expense insurance,
     7  regardless of financial dependence, who is not insured  by  or  eligible
     8  for  coverage  under  any  [employee] employer health benefit plan as an
     9  employee or member, whether insured  or  self-insured,  and  who  lives,
    10  works  or  resides  in New York state or the service area of the insurer
    11  and who is not covered under title XVIII of  the  United  States  Social
    12  Security Act (Medicare).
    13    (2) In addition to the conversion privilege afforded by subsection (e)
    14  of  this  section  and the continuation privilege afforded by subsection
    15  (m) of this section, every group policy delivered or issued for delivery
    16  in this state that provides hospital,  [surgical  or  medical  coverage]

    17  medical  or  surgical expense insurance coverage for other than specific
    18  diseases or accidents only, and which provides [dependent] coverage of a
    19  child that terminates at a specified age, shall, upon application of the
    20  employee, member or [dependent] child, as set  forth  in  [subparagraphs
    21  (B)  or (C)] subparagraph (B) of this paragraph, provide coverage to the
    22  [dependent] child after that specified age and through  age  twenty-nine
    23  without evidence of insurability, subject to all of the terms and condi-
    24  tions of the group policy and the following:
    25    (A)  An  employer shall not be required to pay all or part of the cost
    26  of  coverage  for  a  [dependent]  child  provided  pursuant   to   this
    27  subsection;

    28    (B)  An  employee,  member  or  [dependent]  child who wishes to elect
    29  continuation of coverage pursuant to this subsection shall  request  the
    30  continuation in writing:
    31    (i)  within  sixty  days  following  the date coverage would otherwise
    32  terminate due to reaching the specified age set forth in the group poli-
    33  cy;
    34    (ii) within sixty days after meeting the requirements for  [dependent]
    35  child status set forth in paragraph one of this subsection when coverage
    36  for the [dependent] child previously terminated; or
    37    (iii) during an annual thirty-day open enrollment period, as described
    38  in the policy;
    39    (C) [For twelve months after the effective date of this subsection, an
    40  employee, member or dependent child may elect prospective coverage under

    41  this  subsection  for  a dependent child whose coverage terminated under
    42  the terms of the group policy prior to the  initial  effective  date  of
    43  this subsection;
    44    (D)] An employee, member or [dependent] child electing continuation as
    45  described  in  this  subsection  shall  pay to the group policyholder or
    46  employer, but not more frequently than on a monthly  basis  in  advance,
    47  the  amount  of  the  required  premium  payment on the due date of each
    48  payment. The written election of continuation, together with  the  first
    49  premium payment required to establish premium payment on a monthly basis
    50  in  advance, shall be given to the group policyholder or employer within
    51  the time periods set forth in [subparagraphs (B) and  (C)]  subparagraph

    52  (B) of this paragraph. Any premium received within the thirty-day period
    53  after the due date shall be considered timely;
    54    [(E)]  (D)  For  any  [dependent] child electing coverage within sixty
    55  days of the date the [dependent] child would otherwise lose coverage due
    56  to reaching a specified age, the  effective  date  of  the  continuation

        S. 5800                            15
 
     1  coverage shall be the date coverage would have otherwise terminated. For
     2  any  [dependent] child electing to resume coverage during an annual open
     3  enrollment period [or during the twelve-month  initial  open  enrollment
     4  period  described  in subparagraph (C) of this paragraph], the effective
     5  date of the continuation coverage shall be  prospective  no  later  than

     6  thirty days after the election and payment of first premium;
     7    [(F)] (E) Coverage for a [dependent] child pursuant to this subsection
     8  shall  consist of coverage that is identical to the coverage provided to
     9  the employee or member parent. If coverage is modified under the  policy
    10  for  any  group  of  similarly  situated  employees or members, then the
    11  coverage shall also be modified in the same manner for  any  [dependent]
    12  child;
    13    [(G)]  (F)  Coverage  shall  terminate  on  the  first to occur of the
    14  following:
    15    (i) the date the [dependent] child no longer meets the requirements of
    16  paragraph one of this subsection;
    17    (ii) the end of the period for which premium payments  were  made,  if
    18  there  is a failure to make payment of a required premium payment within

    19  the period of grace described in subparagraph [(D)] (C)  of  this  para-
    20  graph; or
    21    (iii)  the  date  on  which  the  group  policy  is terminated and not
    22  replaced by coverage under another group policy; and
    23    [(H)] (G) The  insurer  shall  provide  written  notification  of  the
    24  continuation  privilege described in this subsection and the time period
    25  in which to request continuation to the employee or member:
    26    (i) in each certificate of coverage; and
    27    (ii) at least sixty days prior to termination at the specified age  as
    28  provided in the policy[; and
    29    (iii)  within  thirty  days  of the effective date of this subsection,
    30  with respect to information concerning a dependent child's  opportunity,

    31  for twelve months after the effective date of this subsection, to make a
    32  written  election to obtain coverage under a policy pursuant to subpara-
    33  graph (C) of this paragraph].
    34    § 23. Section 3232 of the insurance law is amended by adding four  new
    35  subsections (f), (g), (h) and (i) to read as follows:
    36    (f)  With  respect to an individual under age nineteen, an insurer may
    37  not impose any pre-existing condition  exclusion  in  an  individual  or
    38  group policy of hospital, medical, surgical or prescription drug expense
    39  insurance  pursuant  to  the  requirements of section 2704 of the Public
    40  Health Service Act, 42 U.S.C. § 300gg-3, as made  effective  by  section
    41  1255(2)  of  the Affordable Care Act, except for an individual under age

    42  nineteen covered under an individual policy of hospital, medical, surgi-
    43  cal or prescription drug  expense  insurance  that  is  a  grandfathered
    44  health plan.
    45    (g)  Beginning  January  first,  two  thousand  fourteen,  pursuant to
    46  section 2704 of the Public Health Service Act, 42 U.S.C. §  300gg-3,  an
    47  insurer  may not impose any pre-existing condition exclusion in an indi-
    48  vidual or group policy of hospital, medical,  surgical  or  prescription
    49  drug expense insurance except in an individual policy that is a grandfa-
    50  thered health plan.
    51    (h)  The requirements of subsections (f) and (g) of this section shall
    52  also be applicable to a blanket policy of hospital, medical, surgical or
    53  prescription drug expense insurance.

    54    (i) For purposes of subsections (f) and (g) of this section, "grandfa-
    55  thered health plan" means coverage provided by an insurer  in  which  an
    56  individual  was  enrolled on March twenty-third, two thousand ten for as

        S. 5800                            16
 
     1  long as the coverage maintains grandfathered status in  accordance  with
     2  section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).
     3    §  24.  Paragraphs  1  and  2 of subsection (f) of section 4235 of the
     4  insurance law, paragraph 1 as amended by chapter  240  of  the  laws  of
     5  2009, and paragraph 2 as amended by chapter 312 of the laws of 2002, are
     6  amended to read as follows:
     7    (1)  (A)  Any policy of group accident, group health or group accident

     8  and health insurance may include  provisions  for  the  payment  by  the
     9  insurer  of  benefits  for  expenses  incurred  on  account of hospital,
    10  medical or  surgical  care  or  physical  and  occupational  therapy  by
    11  licensed  physical  and occupational therapists upon the prescription or
    12  referral of a physician for the employee or other member of the  insured
    13  group,  [his] the employee's or member's spouse, [his] the employee's or
    14  member's child or children, or  other  persons  chiefly  dependent  upon
    15  [him] the employee or member for support and maintenance; provided that:
    16    (i)  a  policy  of  hospital,  medical, surgical, or prescription drug
    17  expense insurance that provides coverage for children shall provide such

    18  coverage to a married or unmarried child until attainment of  age  twen-
    19  ty-six,  without  regard  to  financial  dependence,  residency with the
    20  employee or member, student status, or employment, except a policy  that
    21  is  a  grandfathered  health  plan  may, for plan years beginning before
    22  January first, two thousand fourteen, exclude coverage of an adult child
    23  under age twenty-six who is eligible to enroll in an  employer-sponsored
    24  health  plan other than a group health plan of a parent. For purposes of
    25  this item, "grandfathered health plan" means  coverage  provided  by  an
    26  insurer  in  which an individual was enrolled on March twenty-third, two
    27  thousand ten for as long as the coverage maintains grandfathered  status

    28  in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
    29  § 18011(e); and
    30    (ii)  a  policy under which coverage [of a dependent of an employee or
    31  other member of the insured group] terminates at a specified  age  shall
    32  not  so terminate with respect to an unmarried child who is incapable of
    33  self-sustaining employment by reason of  mental  illness,  developmental
    34  disability, mental retardation, as defined in the mental hygiene law, or
    35  physical handicap and who became so incapable prior to attainment of the
    36  age  at  which [dependent] coverage would otherwise terminate and who is
    37  chiefly dependent upon such employee or member for support  and  mainte-
    38  nance,  while  the  insurance of the employee or member remains in force

    39  and the [dependent] child remains in  such  condition,  if  the  insured
    40  employee  or  member  has  within  thirty-one days of such [dependent's]
    41  child's attainment of  the  termination  age  submitted  proof  of  such
    42  [dependent's] child's incapacity as described herein.
    43    (B)  In addition to the requirements of subparagraph (A) of this para-
    44  graph, every insurer issuing a group  policy  of  hospital,  medical  or
    45  surgical expense insurance pursuant to this section that provides cover-
    46  age  for  [dependent]  children, must make available and if requested by
    47  the policyholder, extend coverage under the policy to an unmarried child
    48  through age twenty-nine, without regard to financial dependence  who  is
    49  not  insured by or eligible for coverage under any employer health bene-

    50  fit plan as an employee or member, whether insured or self-insured,  and
    51  who lives, works or resides in New York state or the service area of the
    52  insurer.  Such  coverage shall be made available at the inception of all
    53  new policies and with respect to all other policies at  any  anniversary
    54  date.  Written  notice  of  the  availability  of such coverage shall be
    55  delivered to the policyholder prior to the inception of such group poli-
    56  cy and annually thereafter.

        S. 5800                            17
 
     1    (2) Notwithstanding any rule, regulation or law to the  contrary,  any
     2  family coverage available under this article shall provide that coverage
     3  of  newborn infants, including newly born infants adopted by the insured
     4  or subscriber if such insured or subscriber takes  physical  custody  of

     5  the  infant  upon  such  infant's  release from the hospital and files a
     6  petition pursuant to section  one  hundred  fifteen-c  of  the  domestic
     7  relations  law within thirty days of birth; and provided further that no
     8  notice of revocation to the adoption has been filed pursuant to  section
     9  one  hundred  fifteen-b of the domestic relations law and consent to the
    10  adoption has not been revoked, shall be effective  from  the  moment  of
    11  birth  for injury or sickness including the necessary care and treatment
    12  of  medically  diagnosed  congenital  defects  and  birth  abnormalities
    13  including premature birth, except that in cases of adoption, coverage of
    14  the initial hospital stay shall not be required where a birth parent has
    15  insurance coverage available for the infant's care. In the case of indi-
    16  vidual  coverage  the  insurer  must  also permit the person to whom the

    17  certificate is issued to elect such coverage of newborn infants from the
    18  moment of birth. If notification and/or payment of an additional premium
    19  or contribution is required to make coverage  effective  for  a  newborn
    20  infant, the coverage may provide that such notice and/or payment be made
    21  within  no  less  than  thirty days of the day of birth to make coverage
    22  effective from the moment of birth. This election shall not be  required
    23  in  the  case  of  student  insurance or where the group's plan does not
    24  provide coverage for [dependent] children.
    25    § 25. Paragraph 2 of subsection (a) of section 4303 of  the  insurance
    26  law,  as added by chapter 705 of the laws of 1996, is amended to read as
    27  follows:
    28    (2) (A) For services to  treat  an  emergency  condition  in  hospital
    29  facilities[.]:

    30    (i) without the need for any prior authorization determination;
    31    (ii)  regardless  of  whether the health care provider furnishing such
    32  services is a participating provider with respect to such services;
    33    (iii) if the emergency services are provided  by  a  non-participating
    34  provider,  without imposing any administrative requirement or limitation
    35  on coverage that is more restrictive than the  requirements  or  limita-
    36  tions  that  apply  to  emergency  services  received from participating
    37  providers; and
    38    (iv) if the emergency services are  provided  by  a  non-participating
    39  provider,  the  cost-sharing  requirement  (expressed  as a copayment or
    40  coinsurance) shall be the same requirement  that  would  apply  if  such

    41  services were provided by a participating provider.
    42    (B)  Any requirements of section 2719A(b) of the Public Health Service
    43  Act, 42 U.S.C.  § 300gg19a(b) and regulations thereunder that exceed the
    44  requirements of this paragraph with respect  to  coverage  of  emergency
    45  services  shall  be  applicable  to every contract subject to this para-
    46  graph.
    47    (C) For the purpose of this provision, "emergency condition"  means  a
    48  medical  or  behavioral  condition[, the onset of which is sudden,] that
    49  manifests itself by acute symptoms  of  sufficient  severity,  including
    50  severe  pain, such that a prudent layperson, possessing an average know-
    51  ledge of medicine and health, could reasonably  expect  the  absence  of

    52  immediate medical attention to result in [(A)] (i) placing the health of
    53  the  person afflicted with such condition in serious jeopardy, or in the
    54  case of a behavioral condition placing the  health  of  such  person  or
    55  others  in  serious  jeopardy[, or (B)]; (ii) serious impairment to such
    56  person's bodily functions; [(C)] (iii) serious dysfunction of any bodily

        S. 5800                            18
 
     1  organ or part of such person; [or (D)]  (iv)  serious  disfigurement  of
     2  such  person;  or (v) a condition described in clause (i), (ii) or (iii)
     3  of section 1867(e)(1)(A) of the Social Security Act.
     4    (D)  For  the  purpose  of this provision, "emergency services" means,

     5  with respect to an emergency condition: (i) a medical screening examina-
     6  tion as required under section 1867  of  the  Social  Security  Act,  42
     7  U.S.C. § 1395dd, which is within the capability of the emergency depart-
     8  ment  of a hospital, including ancillary services routinely available to
     9  the emergency department to evaluate such emergency  medical  condition;
    10  and  (ii)  within the capabilities of the staff and facilities available
    11  at the hospital, such further medical examination and treatment  as  are
    12  required  under  section  1867  of the Social Security Act, 42 U.S.C.  §
    13  1395dd, to stabilize the patient.
    14    (E) For the purpose of this  provision,  "to  stabilize"  means,  with

    15  respect  to an emergency condition, to provide such medical treatment of
    16  the condition as may be necessary to assure, within  reasonable  medical
    17  probability,  that  no material deterioration of the condition is likely
    18  to result from or occur during the transfer of  the  subscriber  from  a
    19  facility or to deliver a newborn child (including the placenta).
    20    §  26. Subsection (j) of section 4303 of the insurance law, as amended
    21  by chapter 728 of the laws of 1993, is amended to read as follows:
    22    (j)(1) A health  service  corporation  or  medical  expense  indemnity
    23  corporation  [which]  that  provides  medical,  major-medical or similar
    24  comprehensive-type  coverage  [must]  shall  provide  coverage  for  the
    25  provision of preventive and primary care services.

    26    (2)  For  purposes  of  this  paragraph  and  paragraph  one  of  this
    27  subsection, preventive and primary care services shall mean the  follow-
    28  ing  services  rendered  to  a [dependent] covered child of a subscriber
    29  from the date of birth through the attainment of nineteen years of age:
    30    [(i)] (A) an initial hospital check-up and well-child visits scheduled
    31  in accordance with the prevailing clinical standards of a national asso-
    32  ciation of pediatric physicians designated by the commissioner of health
    33  (except for any standard that would limit  the  specialty  or  forum  of
    34  licensure  of  the  practitioner  providing  the  service other than the
    35  limits under state law). Coverage for such services  rendered  shall  be
    36  provided  only to the extent that such services are provided by or under

    37  the supervision of a physician, or  other  professional  licensed  under
    38  article  one  hundred  thirty-nine  of  the education law whose scope of
    39  practice pursuant to such law includes  the  authority  to  provide  the
    40  specified  services.  Coverage  shall  be  provided  for  such  services
    41  rendered in a hospital, as defined in section twenty-eight  hundred  one
    42  of  the  public  health  law,  or  in  an office of a physician or other
    43  professional licensed under  article  one  hundred  thirty-nine  of  the
    44  education  law whose scope of practice pursuant to such law includes the
    45  authority to provide the specified services,
    46    [(ii)] (B) at each visit, services in accordance with  the  prevailing
    47  clinical  standards  of such designated association, including a medical
    48  history, a  complete  physical  examination,  developmental  assessment,

    49  anticipatory  guidance,  appropriate  immunizations and laboratory tests
    50  which tests are ordered at the time of the visit and  performed  in  the
    51  practitioner's  office, as authorized by law, or in a clinical laborato-
    52  ry, and
    53    [(iii)] (C) necessary immunizations, as determined by the  superinten-
    54  dent  in  consultation with the commissioner of health, consisting of at
    55  least adequate dosages of vaccine against diphtheria,  pertussis,  teta-
    56  nus,  polio,  measles, rubella, mumps, haemophilus influenzae type b and

        S. 5800                            19
 
     1  hepatitis b, which meet the standards  approved  by  the  United  States
     2  public health service for such biological products.
     3    (D)  Such  coverage  required pursuant to this paragraph and paragraph

     4  one of this subsection  shall  not  be  subject  to  annual  deductibles
     5  [and/or] or coinsurance.
     6    (E)  Such  coverage  required pursuant to this paragraph and paragraph
     7  one of this subsection shall not restrict or eliminate existing coverage
     8  provided by the contract.
     9    (3) In addition to paragraph one or  two  of  this  subsection,  every
    10  contract  that  provides  hospital,  surgical  or medical care coverage,
    11  except for a grandfathered health plan  under  paragraph  four  of  this
    12  subsection, shall provide coverage for the following preventive care and
    13  screenings  for  subscribers,  and such coverage shall not be subject to
    14  annual deductibles or coinsurance:

    15    (A) evidence-based items or services for preventive care  and  screen-
    16  ings that have in effect a rating of 'A' or 'B' in the current recommen-
    17  dations of the United States preventive services task force;
    18    (B)  immunizations that have in effect a recommendation from the advi-
    19  sory committee on immunization practices  of  the  centers  for  disease
    20  control and prevention with respect to the individual involved;
    21    (C)  with  respect  to  children,  including  infants and adolescents,
    22  evidence-informed preventive care and screenings provided for in compre-
    23  hensive guidelines supported by the health resources and services admin-
    24  istration; and
    25    (D) with respect to women, such additional preventive care and screen-

    26  ings not described in subparagraph (A) of this paragraph and as provided
    27  for in comprehensive guidelines supported by the  health  resources  and
    28  services administration.
    29    (4) For purposes of this subsection, "grandfathered health plan" means
    30  coverage  provided  by a corporation in which an individual was enrolled
    31  on March twenty-third, two thousand ten for  as  long  as  the  coverage
    32  maintains grandfathered status in accordance with section 1251(e) of the
    33  Affordable Care Act, 42 U.S.C. § 18011(e).
    34    §  27. Subsection (p) of section 4303 of the insurance law, as amended
    35  by chapter 554 of the laws of 2002, is amended to read as follows:
    36    (p) (1) A medical expense indemnity corporation,  a  hospital  service

    37  corporation or a health service corporation [which] that provides cover-
    38  age  for  hospital, surgical or medical care shall provide the following
    39  coverage for mammography screening for occult breast cancer:
    40    (A) upon the recommendation of a physician, a mammogram at any age for
    41  covered persons having a prior history of breast cancer or  who  have  a
    42  first degree relative with a prior history of breast cancer;
    43    (B)  a  single baseline mammogram for covered persons aged thirty-five
    44  through thirty-nine, inclusive; and
    45    (C) an annual mammogram for covered persons aged forty and older.
    46    (D) The coverage required in this paragraph or paragraph two  of  this
    47  subsection  may  be subject to annual deductibles and coinsurance as may
    48  be deemed appropriate by the superintendent and as are  consistent  with

    49  those established for other benefits within a given [policy] contract.
    50    (2)  [In no event shall coverage pursuant to this section include more
    51  than one annual screening.
    52    (3)] For purposes of paragraph one  of  this  subsection,  mammography
    53  screening  means  an  X-ray  examination  of  the breast using dedicated
    54  equipment, including X-ray tube, filter,  compression  device,  screens,
    55  films  and cassettes, with an average glandular radiation dose less than
    56  0.5 rem per view per breast.

        S. 5800                            20
 
     1    (3) In addition to paragraph one or  two  of  this  subsection,  every
     2  contract  that provides coverage for hospital, surgical or medical care,

     3  except for a grandfathered health plan  under  paragraph  four  of  this
     4  subsection, shall provide coverage for the following mammography screen-
     5  ing  services,  and such coverage shall not be subject to annual deduct-
     6  ibles or coinsurance:
     7    (A) evidence-based items or services  for  mammography  that  have  in
     8  effect  a  rating  of  'A'  or 'B' in the current recommendations of the
     9  United States preventive services task force; and
    10    (B) with respect to women, such additional preventive care and screen-
    11  ings for mammography not described in subparagraph (A) of this paragraph
    12  and as provided for in comprehensive guidelines supported by the  health
    13  resources and services administration.

    14    (4) For purposes of this subsection, "grandfathered health plan" means
    15  coverage  provided  by a corporation in which an individual was enrolled
    16  on March twenty-third, two thousand ten for  as  long  as  the  coverage
    17  maintains grandfathered status in accordance with section 1251(e) of the
    18  Affordable Care Act, 42 U.S.C. § 18011(e).
    19    §  28. Subsection (t) of section 4303 of the insurance law, as amended
    20  by chapter 43 of the laws of 1993 and paragraph 1 as amended by  chapter
    21  554 of the laws of 2002, is amended to read as follows:
    22    (t)  (1)  A  medical expense indemnity corporation, a hospital service
    23  corporation or a health service corporation [which] that provides cover-
    24  age for hospital, surgical, or medical care shall provide  coverage  for

    25  an  annual  cervical  cytology  screening  for  cervical  cancer and its
    26  precursor states for  women  aged  eighteen  and  older.  Such  coverage
    27  required  by  this  paragraph  may  be subject to annual deductibles and
    28  coinsurance as may be deemed appropriate by the  superintendent  and  as
    29  are  consistent with those established for other benefits within a given
    30  contract.
    31    (2) For purposes of paragraph one of this subsection, cervical cytolo-
    32  gy screening shall include an annual pelvic examination, collection  and
    33  preparation  of  a  Pap  smear,  and  laboratory and diagnostic services
    34  provided in connection with examining and evaluating the Pap smear.
    35    (3) In addition to paragraph one or  two  of  this  subsection,  every
    36  contract  that provides coverage for hospital, surgical or medical care,

    37  except for a grandfathered health plan  under  paragraph  four  of  this
    38  subsection,  shall  provide coverage for the following cervical cytology
    39  screening services, and such coverage shall not  be  subject  to  annual
    40  deductibles or coinsurance:
    41    (A)  evidence-based  items or services for cervical cytology that have
    42  in effect a rating of 'A' or 'B' in the current recommendations  of  the
    43  United States preventive services task force; and
    44    (B) with respect to women, such additional preventive care and screen-
    45  ings  for  cervical  cytology  not described in subparagraph (A) of this
    46  paragraph and as provided for in comprehensive guidelines  supported  by
    47  the health resources and services administration.

    48    (4) For purposes of this subsection, "grandfathered health plan" means
    49  coverage  provided  by a corporation in which an individual was enrolled
    50  on March twenty-third, two thousand ten for  as  long  as  the  coverage
    51  maintains grandfathered status in accordance with section 1251(e) of the
    52  Affordable Care Act, 42 U.S.C. § 18011(e).
    53    §  29. Paragraph 5 of subsection (aa) of section 4303 of the insurance
    54  law, as added by chapter 506 of the laws of 2001, is amended to read  as
    55  follows:
    56    (5) As used in this subsection:

        S. 5800                            21
 
     1    (A)  "Prehospital  emergency medical services" means the prompt evalu-
     2  ation and treatment of an emergency medical condition,  and/or  non-air-

     3  borne  transportation  of  the  patient to a hospital; provided however,
     4  where the patient utilizes non-air-borne emergency transportation pursu-
     5  ant to this subsection, reimbursement [will] shall be based on whether a
     6  prudent  layperson,  possessing  an  average  knowledge  of medicine and
     7  health, could reasonably expect the absence of  such  transportation  to
     8  result  in  (i)  placing  the  health  of the person afflicted with such
     9  condition in serious jeopardy, or in the case of a behavioral  condition
    10  placing  the  health  of such person or others in serious jeopardy; (ii)
    11  serious impairment to such  person's  bodily  functions;  (iii)  serious
    12  dysfunction  of any bodily organ or part of such person; [or] (iv) seri-
    13  ous disfigurement of such person; or (v) a condition described in clause

    14  (i), (ii) or (iii) of section 1867(e)(1)(A) of the Social Security Act.
    15    (B) "Emergency condition" means a medical  or  behavioral  condition[,
    16  the  onset  of which is sudden,] that manifests itself by acute symptoms
    17  of sufficient severity, including  severe  pain,  such  that  a  prudent
    18  layperson, possessing an average knowledge of medicine and health, could
    19  reasonably  expect  the absence of immediate medical attention to result
    20  in (i) placing the health of the person afflicted with such condition in
    21  serious jeopardy, or in the case of a behavioral condition, placing  the
    22  health  of  such  person  or  others  in  serious jeopardy; (ii) serious
    23  impairment to such person's bodily functions; (iii) serious  dysfunction
    24  of any bodily organ or part of such person; [or] (iv) serious disfigure-

    25  ment of such person; or (v) a condition described in clause (i), (ii) or
    26  (iii) of section 1867(e)(1)(A) of the Social Security Act.
    27    §  30.  Subsection (bb) of section 4303 of the insurance law, as added
    28  by chapter 554 of the laws of 2002, is amended to read as follows:
    29    (bb) A health service corporation or a medical service expense  indem-
    30  nity  corporation [which] that provides major medical or similar compre-
    31  hensive-type coverage shall  provide  such  coverage  for  bone  mineral
    32  density  measurements  or tests, and if such contract otherwise includes
    33  coverage for prescription drugs,  drugs  and  devices  approved  by  the
    34  federal  food and drug administration or generic equivalents as approved
    35  substitutes. In determining appropriate coverage provided by [this para-

    36  graph] paragraphs one, two and three of this subsection, the insurer  or
    37  health  maintenance  organization  shall  adopt  standards  [which] that
    38  include the criteria of the federal [medicare] Medicare program and  the
    39  criteria  of  the  national  institutes  of  health for the detection of
    40  osteoporosis, provided that such coverage shall be further determined as
    41  follows:
    42    (1) For purposes of paragraphs two and three of this subsection,  bone
    43  mineral  density  measurements or tests, drugs and devices shall include
    44  those covered under the criteria  of  the  federal  [medicare]  Medicare
    45  program as well as those in accordance with the criteria of the national
    46  institutes of health, including, as consistent with such criteria, dual-
    47  energy x-ray absorptiometry.

    48    (2)  For purposes of paragraphs one and three of this subsection, bone
    49  mineral density measurements  or  tests,  drugs  and  devices  shall  be
    50  covered  for  individuals  meeting the criteria for coverage, consistent
    51  with the criteria under the federal [medicare] Medicare program  or  the
    52  criteria  of  the  national  institutes of health; provided that, to the
    53  extent consistent with such criteria, individuals qualifying for  cover-
    54  age shall, at a minimum, include individuals:
    55    (i)  previously  diagnosed  as  having osteoporosis or having a family
    56  history of osteoporosis; or

        S. 5800                            22
 
     1    (ii) with symptoms or conditions indicative of the  presence,  or  the
     2  significant risk, of osteoporosis; or
     3    (iii) on a prescribed drug regimen posing a significant risk of osteo-

     4  porosis; or
     5    (iv)  with  lifestyle factors to such a degree as posing a significant
     6  risk of osteoporosis; or
     7    (v) with such age, gender and/or other  physiological  characteristics
     8  which pose a significant risk for osteoporosis.
     9    (3)  Such  coverage  required pursuant to paragraph one or two of this
    10  subsection may be subject to annual deductibles and coinsurance  as  may
    11  be  deemed  appropriate by the superintendent and as are consistent with
    12  those established for other benefits within a given policy.
    13    (4) In addition to paragraph one, two or  three  of  this  subsection,
    14  every  contract  that provides hospital, surgical or medical care cover-
    15  age, except for a grandfathered health plan under paragraph five of this

    16  subsection, shall provide coverage for the following items  or  services
    17  for  bone  mineral  density,  and  such coverage shall not be subject to
    18  annual deductibles or coinsurance:
    19    (A) evidence-based items or services for  bone  mineral  density  that
    20  have  in effect a rating of 'A' or 'B' in the current recommendations of
    21  the United States preventive services task force; and
    22    (B) with respect to women, such additional preventive care and screen-
    23  ings for bone mineral density not described in subparagraph (A) of  this
    24  paragraph  and  as provided for in comprehensive guidelines supported by
    25  the health resources and services administration.
    26    (5) For purposes of this subsection, "grandfathered health plan" means

    27  coverage provided by a corporation in which an individual  was  enrolled
    28  on  March  twenty-third,  two  thousand  ten for as long as the coverage
    29  maintains grandfathered status in accordance with section 1251(e) of the
    30  Affordable Care Act, 42 U.S.C. § 18011(e).
    31    § 31. Paragraphs 1 and 3 of subsection (d)  of  section  4304  of  the
    32  insurance law, paragraph 1 as amended by chapter 240 of the laws of 2009
    33  and  paragraph 3 as added by chapter 93 of the laws of 1989, are amended
    34  to read as follows:
    35    (1) (A) No contract issued pursuant to this section shall entitle more
    36  than one person to benefits except that a contract issued and marked  as
    37  a  "family  contract"  may provide that benefits will be furnished to [a
    38  husband and wife, or husband, wife and their dependent  child  or  chil-

    39  dren,  or]  the contract holder, spouse, dependent child or children, or
    40  other person chiefly dependent upon the contract holder provided that:
    41    (i) A "family contract" may provide coverage to any child or  children
    42  not over nineteen years of age, provided that an unmarried student at an
    43  accredited  institution  of learning may be considered a dependent until
    44  [he] the child becomes twenty-three years of age, and provided also that
    45  the coverage of any such "family contract" may include, at the option of
    46  the [insurer] corporation, any unmarried child until attaining age twen-
    47  ty-five[, and provided also that the]. However, a "family  contract"  of
    48  hospital, medical, surgical, or prescription drug expense insurance that

    49  provides  coverage for dependent children shall provide such coverage to
    50  a married or unmarried child until attainment of age twenty-six  without
    51  regard  to  financial  dependence,  residency with the contract  holder,
    52  student status, or employment.
    53    (ii) The coverage of any such  "family  contract"  shall  include  any
    54  other  unmarried child, regardless of age, who is incapable of self-sus-
    55  taining employment by reason of mental illness, developmental  disabili-
    56  ty,  mental  retardation, as defined in the mental hygiene law, or phys-

        S. 5800                            23
 
     1  ical handicap and who became so incapable prior to attainment of the age
     2  at which [dependent] coverage would otherwise terminate[, so  that  such

     3  child may be considered a dependent].
     4    (B)  In addition to the requirements of subparagraph (A) of this para-
     5  graph, every corporation issuing a  contract  of  hospital,  medical  or
     6  surgical  expense insurance that provides coverage for [dependent] chil-
     7  dren must make available and if requested by the contractholder,  extend
     8  coverage  under  the  contract to an unmarried child through age twenty-
     9  nine, without regard to financial dependence who is not  insured  by  or
    10  eligible  for coverage under any [employee] employer health benefit plan
    11  as an employee or member,  whether  insured  or  self-insured,  and  who
    12  lives,  works  or  resides  in New York state or the service area of the
    13  corporation. Such coverage shall be made available at the  inception  of

    14  all  new contracts, [at the first anniversary date of a policy following
    15  the effective date of  this  subparagraph,]  and  for  group  remittance
    16  contracts at any anniversary date. Written notice of the availability of
    17  such  coverage  shall  be  delivered  to the contractholder prior to the
    18  inception of such [group] contract, [thirty  days  prior  to  the  first
    19  anniversary  date  of  a  policy  following  the  effective date of this
    20  subparagraph,] and for group remittance contracts annually thereafter.
    21    (C) Notwithstanding any rule, regulation or law to the  contrary,  any
    22  "family  contract"  shall  provide  that  coverage  of  newborn infants,
    23  including newly born infants adopted by the [insured or]  subscriber  if

    24  such  [insured  or] subscriber takes physical custody of the infant upon
    25  such infant's release from the hospital and files a petition pursuant to
    26  section one hundred fifteen-c of the domestic relations law within thir-
    27  ty days of birth; and provided further that no notice of  revocation  to
    28  the adoption has been filed pursuant to section one hundred fifteen-b of
    29  the  domestic  relations  law  and  consent to the adoption has not been
    30  revoked, shall be effective from the moment of birth for injury or sick-
    31  ness including the necessary care and treatment of  medically  diagnosed
    32  congenital  defects  and  birth abnormalities including premature birth,
    33  except that in cases of adoption, coverage of the initial hospital  stay
    34  shall not be required where a birth parent has insurance coverage avail-
    35  able for the infant's care. This provision regarding coverage of newborn

    36  infants  shall not apply to two person coverage. In the case of individ-
    37  ual or two person coverages the corporation must also permit the  person
    38  to  whom  the  [policy]  contract  is  issued  to elect such coverage of
    39  newborn infants from the moment of birth. If notification and/or payment
    40  of an additional premium or contribution is required  to  make  coverage
    41  effective  for  a  newborn  infant,  the  coverage may provide that such
    42  notice and/or payment be made within no less than thirty days of the day
    43  of birth to make coverage effective  from  the  moment  of  birth.  This
    44  election shall not be required in the case of student insurance or where
    45  the  group remitting agent's plan does not provide coverage for [depend-
    46  ent] children.
    47    (3) Coverage of an unmarried dependent child who is incapable of self-

    48  sustaining employment by reason of mental illness,  developmental  disa-
    49  bility  or  mental retardation, as defined in the mental hygiene law, or
    50  physical handicap and who became so incapable prior to attainment of the
    51  age at which [dependent] coverage would otherwise terminate and  who  is
    52  chiefly  dependent upon the contract holder for support and maintenance,
    53  shall not terminate while the [policy] contract remains in force and the
    54  [dependent] child remains  in  such  condition,  if  the  [policyholder]
    55  contract holder has within thirty-one days of such [dependent's] child's

        S. 5800                            24
 
     1  attainment  of  the  limiting  age submitted proof of such [dependent's]

     2  child's incapacity as described herein.
     3    §  32.  Subsection (e) of section 4304 of the insurance law is amended
     4  by adding a new paragraph 5 to read as follows:
     5    (5) For purposes  of  this  subsection,  the  term  "dependent"  shall
     6  include a child as described in subsection (d) of this section.
     7    §  33.  Paragraph 5 of subsection (k) of section 4304 of the insurance
     8  law, as added by chapter 236 of the laws of 2009,  is  renumbered  para-
     9  graph 6 and a new paragraph 7 is added to read as follows:
    10    (7)  For  purposes  of  this  subsection,  the  term "dependent" shall
    11  include a child as described in subsection (d) of this section.
    12    § 34. Paragraphs 1 and 2 of subsection (m)  of  section  4304  of  the
    13  insurance  law, as added by chapter 240 of the laws of 2009, are amended
    14  to read as follows:

    15    (1) As used in this subsection, ["dependent child"] "child"  means  an
    16  unmarried child through age twenty-nine of an employee or member insured
    17  under  a  group  remittance  contract  of  hospital, medical or surgical
    18  expense insurance,  regardless  of  financial  dependence,  who  is  not
    19  insured by or eligible for coverage under any [employee] employer health
    20  benefit  plan as an employee or member, whether insured or self-insured,
    21  and who lives, works or resides in New York state or the service area of
    22  the corporation and who is not covered under title XVIII of  the  United
    23  States Social Security Act (Medicare).
    24    (2) In addition to the conversion privilege afforded by subsection (e)
    25  of  this  section and the continuation privilege afforded by subsections

    26  (e) and (k) of this section,  a  hospital  service,  health  service  or
    27  medical  expense  corporation  or  health  maintenance organization that
    28  provides hospital, medical or surgical expense  insurance  coverage  for
    29  which  the  premiums  are  paid  by  the remitting agent of a group that
    30  provides [dependent] coverage of a child that terminates at a  specified
    31  age  shall,  upon  application  of  the  employee, member or [dependent]
    32  child, as set forth in subparagraph (B)  [or  (C)]  of  this  paragraph,
    33  provide  coverage  to the [dependent] child after that specified age and
    34  through age twenty-nine without evidence of insurability, subject to all
    35  of the terms and conditions of the group  remittance  contract  and  the
    36  following:
    37    (A)  An  employer shall not be required to pay all or part of the cost

    38  of  coverage  for  a  [dependent]  child  provided  pursuant   to   this
    39  subsection;
    40    (B)  An  employee,  member  or  [dependent]  child who wishes to elect
    41  continuation of coverage pursuant to this subsection shall  request  the
    42  continuation in writing:
    43    (i)  within  sixty  days  following  the date coverage would otherwise
    44  terminate due to reaching the specified  age  set  forth  in  the  group
    45  contract;
    46    (ii)  within sixty days after meeting the requirements for [dependent]
    47  child status set forth in paragraph one of this subsection when coverage
    48  for the [dependent] child previously terminated; or
    49    (iii) during an annual thirty-day open enrollment period as  described
    50  in the contract.
    51    (C) [For twelve months after the effective date of this subsection, an

    52  employee,  member  or dependent child may elect prospective continuation
    53  coverage under this subsection for  a  dependent  child  whose  coverage
    54  terminated under the terms of the group remittance contract prior to the
    55  initial effective date of this subsection;

        S. 5800                            25

     1    (D)] An employee, member or [dependent] child electing continuation as
     2  described  in  this subsection shall pay to the group remitting agent or
     3  employer, but not more frequently than on a monthly  basis  in  advance,
     4  the  amount  of  the  required  premium  payment on the due date of each
     5  payment.  The  written election of continuation, together with the first
     6  premium payment required to establish premium payment on a monthly basis

     7  in advance, shall be given to the  group  remitting  agent  or  employer
     8  within the time periods set forth in [subparagraphs (B) and (C)] subpar-
     9  agraph (B) of this paragraph. Any premium received within the thirty-day
    10  period after the due date shall be considered timely;
    11    [(E)]  (D)  For  any  [dependent] child electing coverage within sixty
    12  days of the date the [dependent] child would otherwise lose coverage due
    13  to reaching a specified age, the  effective  date  of  the  continuation
    14  coverage shall be the date coverage would have otherwise terminated. For
    15  any  [dependent] child electing to resume coverage during an annual open
    16  enrollment period [or during the twelve-month  initial  open  enrollment

    17  period  described  in subparagraph (C) of this paragraph], the effective
    18  date of the continuation coverage shall be  prospective  no  later  than
    19  thirty days after the election and payment of first premium;
    20    [(F)] (E) Coverage for a [dependent] child pursuant to this subsection
    21  shall  consist of coverage that is identical to the coverage provided to
    22  the employee or  member  parent.  If  coverage  is  modified  under  the
    23  contract  for any group of similarly situated employees or members, then
    24  the coverage shall also be modified in the same manner for any  [depend-
    25  ent] child;
    26    [(G)]  (F)  Coverage  shall  terminate  on  the  first to occur of the
    27  following:
    28    (i) the date the [dependent] child no longer meets the requirements of

    29  paragraph one of this subsection;
    30    (ii) the end of the period for which premium payments  were  made,  if
    31  there  is a failure to make payment of a required premium payment within
    32  the period of grace described in subparagraph [(D)] (C)  of  this  para-
    33  graph; or
    34    (iii)  the  date  on which the group remittance contract is terminated
    35  and not replaced by coverage under another  group  or  group  remittance
    36  contract; and
    37    [(H)]  (G)  The  corporation  or health maintenance organization shall
    38  provide written notification of the continuation privilege described  in
    39  this  subsection and the time period in which to request continuation to
    40  the employee or member:
    41    (i) in each certificate of coverage; and
    42    (ii) at least sixty days prior to termination at the specified age  as

    43  provided in the contract[;
    44    (iii)  within  thirty  days  of the effective date of this subsection,
    45  with respect to information concerning a dependent child's  opportunity,
    46  for twelve months after the effective date of this subsection, to make a
    47  written election to obtain coverage under a contract pursuant to subpar-
    48  agraph (C) of this paragraph].
    49    §  35.  Paragraph 1 of subsection (c) of section 4305 of the insurance
    50  law, as amended by chapter 240 of the laws of 2009, is amended  to  read
    51  as follows:
    52    (1)(A)  Any  such contract may provide that benefits will be furnished
    53  to a member of a covered group, for  [himself]  the  member,  [his]  the
    54  member's  spouse,  [his]  child  or  children,  or other persons chiefly

    55  dependent upon [him] the member for support  and  maintenance;  provided
    56  that:

        S. 5800                            26
 
     1    (i)  a  contract  of hospital, medical, surgical, or prescription drug
     2  expense insurance that provides coverage for children shall provide such
     3  coverage to a married or unmarried child until attainment of  age  twen-
     4  ty-six,  without  regard  to  financial  dependence,  residency with the
     5  member,  student  status,  or  employment,  except  a contract that is a
     6  grandfathered health plan may, for plan years beginning  before  January
     7  first,  two  thousand fourteen, exclude coverage of an adult child under
     8  age twenty-six who is eligible to enroll in an employer-sponsored health

     9  plan other than a group health plan of a parent. For  purposes  of  this
    10  item,  "grandfathered  health  plan" means coverage provided by a corpo-
    11  ration in which an individual was enrolled on  March  twenty-third,  two
    12  thousand  ten for as long as the coverage maintains grandfathered status
    13  in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
    14  § 18011(e); and
    15    (ii) a contract under which coverage [of  a  dependent  of  a  member]
    16  terminates  at a specified age shall, with respect to an unmarried child
    17  who is incapable of  self-sustaining  employment  by  reason  of  mental
    18  illness, developmental disability, mental retardation, as defined in the
    19  mental  hygiene  law,  or  physical handicap and who became so incapable

    20  prior to attainment of the  age  at  which  [dependent]  coverage  would
    21  otherwise  terminate  and  who is chiefly dependent upon such member for
    22  support and maintenance, not so terminate while the contract remains  in
    23  force and the [dependent] child remains in such condition, if the member
    24  has  within  thirty-one days of such [dependent's] child's attainment of
    25  the termination age submitted proof of such [dependent's] child's  inca-
    26  pacity as described herein.
    27    (B)  In addition to the requirements of subparagraph (A) of this para-
    28  graph, every corporation issuing a group contract of  hospital,  medical
    29  or  surgical  expense  insurance  pursuant to this section that provides
    30  coverage for [dependent] children, must make available and if  requested

    31  by  the contractholder, extend coverage under that contract to an unmar-
    32  ried child through age twenty-nine, without regard to financial  depend-
    33  ence who is not insured by or eligible for coverage under any [employee]
    34  employer  health  benefit plan as an employee or member, whether insured
    35  or self-insured, and who lives, works or resides in New  York  state  or
    36  the  service area of the corporation. Such coverage shall be made avail-
    37  able at the inception of all new contracts and with respect to all other
    38  contracts at any anniversary date. Written notice of the availability of
    39  such coverage shall be delivered to  the  contractholder  prior  to  the
    40  inception of such group contract and annually thereafter.
    41    (C)  Notwithstanding  any rule, regulation or law to the contrary, any
    42  contract under which a member elects coverage for [himself, his  spouse,

    43  his]  the member, the member's spouse, children or other persons chiefly
    44  dependent upon [him]  the  member  for  support  and  maintenance  shall
    45  provide  that  coverage of newborn infants, including newly born infants
    46  adopted by the [insured  or  subscriber]  member  if  such  [insured  or
    47  subscriber]  member  takes  physical  custody  of  the  infant upon such
    48  infant's release from the hospital and  files  a  petition  pursuant  to
    49  section one hundred fifteen-c of the domestic relations law within thir-
    50  ty  days  of birth; and provided further that no notice of revocation to
    51  the adoption has been filed pursuant to section one hundred fifteen-b of
    52  the domestic relations law and consent to  the  adoption  has  not  been

    53  revoked, shall be effective from the moment of birth for injury or sick-
    54  ness  including  the necessary care and treatment of medically diagnosed
    55  congenital defects and birth abnormalities  including  premature  birth,
    56  except  that in cases of adoption, coverage of the initial hospital stay

        S. 5800                            27
 
     1  shall not be required where a birth parent has insurance coverage avail-
     2  able for the infant's care. This provision regarding coverage of newborn
     3  infants shall not apply to two person coverage. In the case of  individ-
     4  ual  or two person coverages the corporation must also permit the person
     5  to whom the certificate is issued to  elect  such  coverage  of  newborn
     6  infants  from  the moment of birth. If notification and/or payment of an
     7  additional premium or contribution is required to make  coverage  effec-

     8  tive  for  a  newborn  infant, the coverage may provide that such notice
     9  and/or payment be made within no less than thirty days  of  the  day  of
    10  birth to make coverage effective from the moment of birth. This election
    11  shall  not  be  required  in  the case of student insurance or where the
    12  group's plan does not provide coverage for [dependent] children.
    13    § 36. Subsection (d) of section 4305 of the insurance law  is  amended
    14  by adding a new paragraph 5 to read as follows:
    15    (5)  For  purposes  of  this  subsection,  the  term "dependent" shall
    16  include a child as described in subsection (c) of this section.
    17    § 37. Subsection (e) of section 4305 of the insurance law  is  amended
    18  by adding a new paragraph 9 to read as follows:
    19    (9)  For  purposes  of  this  subsection,  the  term "dependent" shall

    20  include a child as described in subsection (c) of this section.
    21    § 38. Subsection (k) of section 4305 of the insurance law  is  amended
    22  by adding a new paragraph 7 to read as follows:
    23    (7)  For  purposes  of  this  subsection,  the  term "dependent" shall
    24  include a child as described in subsection (c) of this section.
    25    § 39. Subsection (l) of section 4305 of the insurance law, as added by
    26  chapter 237 of the laws of 2009, is relettered subsection (m) and  para-
    27  graphs  1  and 2 of subsection (l) of section 4305 of the insurance law,
    28  as added by chapter 240 of the laws of 2009,  are  amended  to  read  as
    29  follows:
    30    (1)  As  used in this subsection, ["dependent child"] "child" means an
    31  unmarried child through age twenty-nine of an employee or member insured

    32  under a group contract of hospital, medical or surgical  expense  insur-
    33  ance,  regardless  of  financial  dependence,  who  is not insured by or
    34  eligible for coverage under any [employee] employer health benefit  plan
    35  as  an  employee  or  member,  whether  insured or self-insured, and who
    36  lives, works or resides in New York state or the  service  area  of  the
    37  corporation  and  who  is  not  covered  under title XVIII of the United
    38  States Social Security Act (Medicare).
    39    (2) In addition to the conversion privilege afforded by subsection (d)
    40  of this section and the continuation privilege  afforded  by  subsection
    41  (e)  of  this  section,  a  hospital  service, health service or medical
    42  expense corporation or health  maintenance  organization  that  provides

    43  group  hospital,  medical  or  surgical coverage under which [dependent]
    44  coverage of a child terminates at a specified age shall,  upon  applica-
    45  tion  of  the  employee,  member  or  [dependent] child, as set forth in
    46  subparagraph (B) [or (C)] of this paragraph,  provide  coverage  to  the
    47  [dependent]  child  after that specified age and through age twenty-nine
    48  without evidence of insurability, subject to all of the terms and condi-
    49  tions of the group contract and the following:
    50    (A) An employer shall not be required to pay all or part of  the  cost
    51  of   coverage   for  a  [dependent]  child  provided  pursuant  to  this
    52  subsection;
    53    (B) An employee, member or  [dependent]  child  who  wishes  to  elect
    54  continuation  of  coverage pursuant to this subsection shall request the

    55  continuation in writing:

        S. 5800                            28
 
     1    (i) within sixty days following  the  date  coverage  would  otherwise
     2  terminate  due  to  reaching  the  specified  age set forth in the group
     3  contract;
     4    (ii)  within sixty days after meeting the requirements for [dependent]
     5  child status set forth in paragraph one of this subsection when coverage
     6  for the [dependent] child previously terminated; or
     7    (iii) during an annual thirty-day open enrollment period, as described
     8  in the contract;
     9    (C) [For twelve months after the effective date of this subsection, an
    10  employee, member or dependent child may elect  prospective  continuation
    11  coverage  under  this  subsection  for  a dependent child whose coverage

    12  terminated under the terms of the group contract prior to the  effective
    13  date of this subsection;
    14    (D)] An employee, member or [dependent] child electing continuation as
    15  described  in  this  subsection shall pay to the group contractholder or
    16  employer, but not more frequently than on a monthly  basis  in  advance,
    17  the  amount  of  the  required  premium  payment on the due date of each
    18  payment. The written election of continuation, together with  the  first
    19  premium payment required to establish premium payment on a monthly basis
    20  in advance, shall be given to the group contractholder or employer with-
    21  in  the  time  periods set forth in [subparagraphs (B) and (C)] subpara-
    22  graph (B) of this paragraph. Any premium received within the  thirty-day

    23  period after the due date shall be considered timely;
    24    [(E)]  (D)  For  any  [dependent] child electing coverage within sixty
    25  days of the date the [dependent] child would otherwise lose coverage due
    26  to reaching a specified age, the  effective  date  of  the  continuation
    27  coverage shall be the date coverage would have otherwise terminated. For
    28  any  [dependent] child electing to resume coverage during an annual open
    29  enrollment period [or during the twelve-month  initial  open  enrollment
    30  period  described  in subparagraph (C) of this paragraph], the effective
    31  date of the continuation coverage shall be  prospective  no  later  than
    32  thirty days after the election and payment of first premium;
    33    [(F)] (E) Coverage for a [dependent] child pursuant to this subsection

    34  shall  consist of coverage that is identical to the coverage provided to
    35  the employee or  member  parent.  If  coverage  is  modified  under  the
    36  contract  for any group of similarly situated employees or members, then
    37  the coverage shall also be modified in the same manner for any  [depend-
    38  ent] child;
    39    [(G)]  (F)  Coverage  shall  terminate  on  the  first to occur of the
    40  following:
    41    (i) the date the [dependent] child no longer meets the requirements of
    42  paragraph one of this subsection;
    43    (ii) the end of the period for which premium payments  were  made,  if
    44  there  is a failure to make payment of a required premium payment within
    45  the period of grace described in subparagraph [(D)] (C)  of  this  para-
    46  graph; or

    47    (iii)  the  date  on  which  the  group contract is terminated and not
    48  replaced by coverage under another group contract; and
    49    [(H)] (G) The corporation or  health  maintenance  organization  shall
    50  provide  written notification of the continuation privilege described in
    51  this subsection and the time period in which to request continuation  to
    52  the employee or member:
    53    (i) in each certificate of coverage; and
    54    (ii)  at least sixty days prior to termination at the specified age as
    55  provided in the contract[;

        S. 5800                            29

     1    (iii) within thirty days of the effective  date  of  this  subsection,
     2  with  respect to information concerning a dependent child's opportunity,

     3  for twelve months after the effective date of this subsection, to make a
     4  written election to obtain coverage under a contract pursuant to subpar-
     5  agraph (C) of this paragraph].
     6    §  40. Section 4306-b of the insurance law, as added by chapter 554 of
     7  the laws of 2002, is amended to read as follows:
     8    § 4306-b. Primary and preventive obstetric and gynecologic care.   (a)
     9  No  corporation  subject  to  the  provisions  of  this article shall by
    10  contract, written policy or procedure limit a female subscriber's direct
    11  access to primary and preventive  obstetric  and  gynecologic  services,
    12  including  annual examinations, care resulting from such annual examina-
    13  tions, and treatment of acute gynecologic conditions, from  a  qualified

    14  provider  of  such  services of her choice from within the plan [to less
    15  than two examinations annually for such services] or [to] for  any  care
    16  related  to  a  pregnancy[.  In addition, no corporation subject to this
    17  article shall by contract, written  policy  or  procedure  limit  direct
    18  access  to  primary  and  preventive  obstetric and gynecologic services
    19  required as a result of such annual examinations or as a  result  of  an
    20  acute gynecologic condition], provided that: (1) such qualified provider
    21  discusses such services and treatment plan with the subscriber's primary
    22  care   practitioner   in   accordance   with  the  requirements  of  the
    23  corporation; and (2) such qualified provider agrees  to  adhere  to  the

    24  corporation's  policies  and procedures, including any applicable proce-
    25  dures regarding referrals and obtaining prior authorization for services
    26  other than obstetric and gynecologic services rendered by such qualified
    27  provider, and agrees to provide services pursuant to  a  treatment  plan
    28  (if any) approved by the corporation.
    29    (b)  A  corporation shall treat the provision of obstetric and gyneco-
    30  logic care, and the ordering of related obstetric and gynecologic  items
    31  and  services, pursuant to the direct access described in subsection (a)
    32  of this section by a participating qualified provider of such  services,
    33  as the authorization of the primary care provider.
    34    (c) It shall be the duty of the administrative officer or other person

    35  in  charge of each corporation subject to the provisions of this article
    36  to advise each female subscriber, in writing, of the provisions of  this
    37  section.
    38    §  41.  The insurance law is amended by adding a new section 4306-d to
    39  read as follows:
    40    § 4306-d. Choice of  health  care  provider.  A  corporation  that  is
    41  subject  to  the provisions of this article and requires or provides for
    42  designation by a subscriber of a  participating  primary  care  provider
    43  shall  permit the subscriber to designate any participating primary care
    44  provider who is available to accept such individual, and in the case  of
    45  a child, shall permit the subscriber to designate a physician (allopath-
    46  ic  or osteopathic) who specializes in pediatrics as the child's primary

    47  care provider if such provider participates in the network of the corpo-
    48  ration.
    49    § 42. The insurance law is amended by adding a new section  4306-e  to
    50  read as follows:
    51    §  4306-e.  Prohibition  on  lifetime and annual limits.  (a) A corpo-
    52  ration shall not establish a lifetime limit  on  the  dollar  amount  of
    53  essential health benefits in an individual, group or blanket contract of
    54  hospital, medical, surgical or prescription drug expense insurance.
    55    (b)  A  corporation  shall not establish an annual limit on the dollar
    56  amount of essential health benefits in an individual, group  or  blanket

        S. 5800                            30
 
     1  contract  of  hospital,  medical,  surgical or prescription drug expense

     2  insurance for contract years beginning on and  after  January  one,  two
     3  thousand fourteen.
     4    (c)  For  contract  years beginning prior to January one, two thousand
     5  fourteen, a corporation may establish restricted annual  limits  on  the
     6  dollar  amount  of  essential health benefits in an individual, group or
     7  blanket contract of hospital, medical,  surgical  or  prescription  drug
     8  expense  insurance  consistent  with  section  2711 of the Public Health
     9  Service Act, 42 U.S.C. § 300gg-11 or any regulations thereunder.
    10    (d) The requirements of subsections (b) and (c) of this section  shall
    11  not  be  applicable  to  any individual contract that is a grandfathered
    12  health plan. For purposes of this section, "grandfathered  health  plan"

    13  means  coverage  provided  by  a  corporation in which an individual was
    14  enrolled on March twenty-third, two thousand ten  for  as  long  as  the
    15  coverage  maintains  grandfathered  status  in  accordance  with section
    16  1251(e) of the Affordable Care Act, 42 U.S.C.  § 18011(e).
    17    (e) For purposes of this section, "essential  health  benefits"  shall
    18  have the meaning ascribed by section 1302(b) of the Affordable Care Act,
    19  42 U.S.C. § 18022(b).
    20    §  43. Section 4318 of the insurance law is amended by adding four new
    21  subsections (f), (g), (h) and (i) to read as follows:
    22    (f) With respect to an individual under age  nineteen,  a  corporation
    23  may  not impose any pre-existing condition exclusion in an individual or

    24  group contract of  hospital,  medical,  surgical  or  prescription  drug
    25  expense  insurance  pursuant  to the requirements of section 2704 of the
    26  Public Health Service Act, 42 U.S.C. § 300gg-3,  as  made  effective  by
    27  section  1255(2)  of  the  Affordable Care Act, except for an individual
    28  under age nineteen covered under an  individual  contract  of  hospital,
    29  medical,  surgical  or  prescription  drug  expense  insurance that is a
    30  grandfathered health plan.
    31    (g) Beginning  January  first,  two  thousand  fourteen,  pursuant  to
    32  section  2704  of  the Public Health Service Act, 42 U.S.C. § 300gg-3, a
    33  corporation may not impose any pre-existing condition  exclusion  in  an

    34  individual   or   group  contract  of  hospital,  medical,  surgical  or
    35  prescription drug expense insurance except  in  an  individual  contract
    36  that is a grandfathered health plan.
    37    (h)  The requirements of subsections (f) and (g) of this section shall
    38  also be applicable to a blanket contract of hospital, medical,  surgical
    39  or prescription drug expense insurance.
    40    (i) For purposes of subsections (f) and (g) of this section, "grandfa-
    41  thered health plan" means coverage provided by a corporation in which an
    42  individual  was  enrolled on March twenty-third, two thousand ten for as
    43  long as the coverage maintains grandfathered status in  accordance  with
    44  section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).

    45    § 44. Subsection (c) of section 4321 of the insurance law, as added by
    46  chapter 504 of the laws of 1995, is amended to read as follows:
    47    (c)  The health maintenance organization shall impose a fifteen dollar
    48  copayment on all visits to a physician or other provider with the excep-
    49  tion of visits for pre-natal and post-natal care [or], well child visits
    50  provided pursuant to paragraph two of subsection  (j)  of  section  four
    51  thousand three hundred three of this article, preventive health services
    52  provided  pursuant  to  subparagraph (F) of paragraph four of subsection
    53  (b) of section four thousand three hundred twenty-two of  this  article,
    54  or  items  or  services  for  bone  mineral density provided pursuant to
    55  subparagraph (D) of paragraph twenty-six of subsection  (b)  of  section

    56  four  thousand  three  hundred  twenty-two  of this article for which no

        S. 5800                            31
 
     1  copayment shall apply. A copayment of fifteen dollars shall  be  imposed
     2  on  equipment,  supplies and self-management education for the treatment
     3  of diabetes. A fifty dollar copayment  shall  be  imposed  on  emergency
     4  services  rendered  in  the  emergency room of a hospital; however, this
     5  copayment  must  be  waived  if  hospital  admission  results.  Surgical
     6  services shall be subject to a copayment of the lesser of twenty percent
     7  of  the  cost  of such services or two hundred dollars per occurrence. A
     8  five hundred dollar copayment shall be  imposed  on  inpatient  hospital
     9  services   per  continuous  hospital  confinement.  Ambulatory  surgical
    10  services shall be subject to a facility copayment charge of seventy-five

    11  dollars. Coinsurance of ten percent shall apply to visits for the  diag-
    12  nosis  and  treatment  of  mental,  nervous  or  emotional  disorders or
    13  ailments.
    14    § 45. Subparagraphs (D) and (E) of paragraph 4 of  subsection  (b)  of
    15  section 4322 of the insurance law, as amended by chapter 554 of the laws
    16  of  2002,  are  amended  and  a new subparagraph (F) is added to read as
    17  follows:
    18    (D) mammography screening, as provided in subsection  (p)  of  section
    19  four thousand three hundred three of this article; [and]
    20    (E)  cervical  cytology  screening  as  provided  in subsection (t) of
    21  section four thousand three hundred three of this article[.]; and
    22    (F) for a contract that  is  not  a  grandfathered  health  plan,  the
    23  following additional preventive health services:

    24    (i)  evidence-based  items or services that have in effect a rating of
    25  'A' or 'B' in the current recommendations of the United  States  preven-
    26  tive services task force;
    27    (ii) immunizations that have in effect a recommendation from the advi-
    28  sory  committee  on  immunization  practices  of the centers for disease
    29  control and prevention with respect to the individual involved;
    30    (iii) with respect to children,  including  infants  and  adolescents,
    31  evidence-informed  preventive  care  and  screenings provided for in the
    32  comprehensive guidelines supported by the health resources and  services
    33  administration; and
    34    (iv)  with  respect  to  women,  such  additional  preventive care and

    35  screenings not described  in  item  (i)  of  this  subparagraph  and  as
    36  provided  for  in  comprehensive  guidelines  supported  by  the  health
    37  resources and services administration.
    38    (v) For purposes of this  subparagraph,  "grandfathered  health  plan"
    39  means  coverage  provided  by  a  corporation in which an individual was
    40  enrolled on March twenty-third, two thousand ten  for  as  long  as  the
    41  coverage  maintains  grandfathered  status  in  accordance  with section
    42  1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).
    43    § 46. Paragraph 26 of subsection (b) of section 4322 of the  insurance
    44  law,  as added by chapter 554 of the laws of 2002, is amended to read as
    45  follows:
    46    (26) Bone mineral density measurements or tests and, if such  contract

    47  otherwise  includes  coverage  for prescription drugs, drugs and devices
    48  approved by the federal food and drug administration or  generic  equiv-
    49  alents as approved substitutes.
    50    In determining appropriate coverage provided by subparagraphs (A), (B)
    51  and  (C)  of this paragraph, the insurer or health maintenance organiza-
    52  tion shall adopt standards [which] that  include  the  criteria  of  the
    53  federal  [medicare]  Medicare  program  and the criteria of the national
    54  institutes of health for the detection of  osteoporosis,  provided  that
    55  such coverage shall be further determined as follows:

        S. 5800                            32
 
     1    (A)  For purposes of subparagraphs (B) and (C) of this paragraph, bone

     2  mineral density measurements or tests, drugs and devices  shall  include
     3  those  covered  under  the  criteria  of the federal [medicare] Medicare
     4  program as well as  those  in  accordance  with  the  criteria,  of  the
     5  national institutes of health, including, as consistent with such crite-
     6  ria dual-energy x-ray absorptiometry.
     7    (B)  For purposes of subparagraphs (A) and (C) of this paragraph, bone
     8  mineral density measurements  or  tests,  drugs  and  devices  shall  be
     9  covered  for  individuals  meeting  the criteria for coverage consistent
    10  with the criteria under the federal [medicare] Medicare program  or  the
    11  criteria  of  the  national  institutes of health; provided that, to the
    12  extent consistent with such criteria, individuals qualifying for  cover-
    13  age shall at a minimum, include individuals:

    14    (i)  previously  diagnosed  as  having osteoporosis or having a family
    15  history of osteoporosis; or
    16    (ii) with symptoms or conditions indicative of the  presence,  or  the
    17  significant risk, of osteoporosis; or
    18    (iii) on a prescribed drug regimen posing a significant risk of osteo-
    19  porosis; or
    20    (iv)  with  lifestyle factors to such a degree as posing a significant
    21  risk of osteoporosis; or
    22    (v) with such age, gender and/or other  physiological  characteristics
    23  which pose a significant risk for osteoporosis.
    24    (C) Such coverage required pursuant to subparagraph (A) or (B) of this
    25  paragraph may be subject to annual deductibles and coinsurance as may be
    26  deemed  appropriate  by  the  superintendent  and as are consistent with
    27  those established for other benefits within a given policy.

    28    (D) In addition to subparagraph (A), (B) or  (C)  of  this  paragraph,
    29  except  for  a  grandfathered health plan under subparagraph (E) of this
    30  paragraph, coverage  shall  be  provided  for  the  following  items  or
    31  services  for  bone  mineral  density,  and  such  coverage shall not be
    32  subject to annual deductibles or coinsurance:
    33    (i) evidence-based items or services for  bone  mineral  density  that
    34  have  in effect a rating of 'A' or 'B' in the current recommendations of
    35  the United States preventive services task force; and
    36    (ii) with respect  to  women,  such  additional  preventive  care  and
    37  screenings  for  bone  mineral density not described in item (i) of this
    38  subparagraph and as provided for in comprehensive  guidelines  supported

    39  by the health resources and services administration.
    40    (E)  For purposes of this paragraph, "grandfathered health plan" means
    41  coverage provided by a corporation in which an individual  was  enrolled
    42  on  March  twenty-third,  two  thousand  ten for as long as the coverage
    43  maintains grandfathered status in accordance with section 1251(e) of the
    44  Affordable Care Act, 42 U.S.C. § 18011(e).
    45    § 47. Subsections (c) and (d) of section 4322 of the insurance law, as
    46  added by chapter 504 of the  laws  of  1995,  are  amended  to  read  as
    47  follows:
    48    (c)  The in-plan benefit system shall impose a ten dollar copayment on
    49  all visits to a physician or other provider with the exception of visits
    50  for pre-natal and post-natal  care  [or],  well  child  visits  provided

    51  pursuant  to  paragraph  two  of subsection (j) of section four thousand
    52  three hundred three of this article, preventive health services provided
    53  pursuant to subparagraph (F) of paragraph four of subsection (b) of this
    54  section or items or services for bone mineral density provided  pursuant
    55  to  subparagraph  (D)  of paragraph twenty-six of subsection (b) of this
    56  section for which no copayment shall apply. A copayment of  ten  dollars

        S. 5800                            33
 
     1  shall  be  imposed  on equipment, supplies and self-management education
     2  for the treatment of diabetes. Coinsurance of ten percent shall apply to
     3  visits for the diagnosis and treatment of mental, nervous  or  emotional
     4  disorders  or  ailments. A thirty-five dollar copayment shall be imposed

     5  on emergency services rendered in the  emergency  room  of  a  hospital;
     6  however, this copayment must be waived if hospital admission results.
     7    (d)  The  out-of-plan  benefit  system shall have an annual deductible
     8  established at one thousand dollars per calendar year for an  individual
     9  and  two  thousand  dollars  per year for a family. Coinsurance shall be
    10  established at twenty percent with the health  maintenance  organization
    11  or  insurer paying eighty percent of the usual, customary and reasonable
    12  charges, or eighty percent of the amounts listed on a fee schedule filed
    13  with and approved by the  superintendent  which  provides  a  comparable
    14  level of reimbursement. Coinsurance of ten percent shall apply to outpa-
    15  tient  visits  for  the  diagnosis  and  treatment of mental, nervous or
    16  emotional disorders or ailments. The benefits described in  subparagraph

    17  (F)  of  paragraph  three  and  paragraphs  seventeen  and  eighteen  of
    18  subsection (b) of this section shall not be subject to the deductible or
    19  coinsurance. The benefits described in paragraph nine of subsection  (b)
    20  of  this section shall not be subject to the deductible. The out-of-plan
    21  out-of-pocket maximum deductible and coinsurance shall be established at
    22  three thousand dollars per calendar year  for  an  individual  and  five
    23  thousand  dollars  per calendar year for a family. The out-of-plan life-
    24  time benefit maximum shall  be  established  at  five  hundred  thousand
    25  dollars  for benefits that are not essential health benefits. A lifetime
    26  limit on the dollar amount of essential health benefits for any individ-
    27  ual shall not be established. For purposes of this  subsection,  "essen-

    28  tial health benefits" shall have the meaning ascribed by section 1302(b)
    29  of the Affordable Care Act, 42 U.S.C. § 18022(b).
    30    §  48.  Paragraphs  13 and 14 of subsection (d) of section 4326 of the
    31  insurance law, as added by chapter 1 of the laws of  1999,  are  amended
    32  and a new paragraph 15 is added to read as follows:
    33    (13)  blood and blood products furnished in connection with surgery or
    34  inpatient hospital services; [and]
    35    (14) prescription drugs obtained at a participating pharmacy. In addi-
    36  tion to providing coverage at a participating pharmacy,  health  mainte-
    37  nance  organizations may utilize a mail order prescription drug program.
    38  Health maintenance organizations may provide prescription drugs pursuant
    39  to a drug formulary;  however,  health  maintenance  organizations  must

    40  implement   an   appeals  process  so  that  the  use  of  non-formulary
    41  prescription drugs may be requested by a physician[.]; and
    42    (15) for a contract that is  not  a  grandfathered  health  plan,  the
    43  following additional preventive health services:
    44    (A)  evidence-based  items or services that have in effect a rating of
    45  'A' or 'B' in the current recommendations of the United  States  preven-
    46  tive services task force;
    47    (B)  immunizations that have in effect a recommendation from the advi-
    48  sory committee on immunization practices  of  the  centers  for  disease
    49  control and prevention with respect to the individual involved;
    50    (C)  with  respect  to  children,  including  infants and adolescents,

    51  evidence-informed preventive care and screenings  provided  for  in  the
    52  comprehensive  guidelines supported by the health resources and services
    53  administration; and
    54    (D) with respect to women, such additional preventive care and screen-
    55  ings not described in subparagraph (A) of this paragraph as provided for

        S. 5800                            34
 
     1  in comprehensive  guidelines  supported  by  the  health  resources  and
     2  services administration.
     3    (E)  For purposes of this paragraph, "grandfathered health plan" means
     4  coverage provided by a corporation in which an individual  was  enrolled
     5  on  March  twenty-third,  two  thousand  ten for as long as the coverage

     6  maintains grandfathered status in accordance with section 1251(e) of the
     7  Affordable Care Act, 42 U.S.C. § 18011(e).
     8    § 49. Paragraphs 6 and 7 of subsection (e)  of  section  4326  of  the
     9  insurance law, as added by chapter 1 of the laws of 1999, are amended to
    10  read as follows:
    11    (6)  (A)  the maximum coverage for prescription drugs in an individual
    12  contract that is a grandfathered health plan  shall  be  three  thousand
    13  dollars per individual in a calendar year; and
    14    (B) the maximum dollar amount on coverage for prescription drugs in an
    15  individual  contract  that  is not a grandfathered health plan or in any
    16  group contract shall be consistent  with  section  2711  of  the  Public
    17  Health Service Act, 42 U.S.C. § 300gg-11 or any regulations thereunder.

    18    (C)  For purposes of this paragraph, "grandfathered health plan" means
    19  coverage provided by a corporation in which an individual  was  enrolled
    20  on  March  twenty-third,  two  thousand  ten for as long as the coverage
    21  maintains grandfathered status in accordance with section 1251(e) of the
    22  Affordable Care Act, 42 U.S.C. § 18011(e); and
    23    (7) all other services shall have a twenty dollar copayment  with  the
    24  exception  of  prenatal  care which shall have a ten dollar copayment or
    25  preventive health services provided pursuant  to  paragraph  fifteen  of
    26  subsection (d) of this section, for which no copayment shall apply.
    27    § 50. Subsection (k) of section 4326 of the insurance law, as added by
    28  chapter 1 of the laws of 1999, is amended to read as follows:

    29    (k)  (1)  All  coverage  under  a  qualifying  group  health insurance
    30  contract or a qualifying individual health insurance  contract  must  be
    31  subject to a pre-existing condition limitation provision as set forth in
    32  sections  three thousand two hundred thirty-two of this chapter and four
    33  thousand three hundred eighteen of this article, including the crediting
    34  requirements thereunder. The underwriting  of  such  contracts  may  not
    35  involve more than the imposition of a pre-existing condition limitation.
    36  However,  as  provided in sections three thousand two hundred thirty-two
    37  of this chapter and four thousand three hundred eighteen of  this  arti-
    38  cle,  a corporation shall not impose a pre-existing condition limitation
    39  provision on any person under age nineteen, except  may  impose  such  a

    40  limitation  on  those  persons covered by a qualifying individual health
    41  insurance contract that is a grandfathered health plan.
    42    (2) Beginning  January  first,  two  thousand  fourteen,  pursuant  to
    43  section  2704  of  the Public Health Service Act, 42 U.S.C. § 300gg-3, a
    44  corporation shall not impose any pre-existing condition limitation in  a
    45  qualifying  group  health  insurance contract or a qualifying individual
    46  health insurance contract except may impose such a limitation in a qual-
    47  ifying individual health insurance  contract  that  is  a  grandfathered
    48  health plan.
    49    (3) For purposes of paragraphs one and two of this subsection, "grand-
    50  fathered  health plan" means coverage provided by a corporation in which

    51  an individual was enrolled on March twenty-third, two thousand  ten  for
    52  as  long  as  the  coverage maintains grandfathered status in accordance
    53  with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).
    54    § 51. Subsection (c) of section 4900 of the insurance law, as added by
    55  chapter 705 of the laws of 1996, is amended to read as follows:

        S. 5800                            35
 
     1    (c) "Emergency condition" means a  medical  or  behavioral  condition,
     2  [the  onset of which is sudden,] that manifests itself by acute symptoms
     3  of sufficient severity, including  severe  pain,  such  that  a  prudent
     4  layperson, possessing an average knowledge of medicine and health, could
     5  reasonably  expect  the absence of immediate medical attention to result

     6  in (1) placing the health of the person afflicted with such condition in
     7  serious jeopardy, or in the case of a behavioral condition  placing  the
     8  health of such person or others in serious jeopardy; (2) serious impair-
     9  ment  to  such person's bodily functions; (3) serious dysfunction of any
    10  bodily organ or part of such person; [or] (4) serious  disfigurement  of
    11  such  person;  or (5) a condition described in clause (i), (ii) or (iii)
    12  of section 1867(e)(1)(A) of the Social Security Act.
    13    § 52. Subsection (g-7) of section 4900 of the insurance law, as  added
    14  by chapter 237 of the laws of 2009, is amended to read as follows:
    15    (g-7) "Rare disease" means a [life threatening or disabling] condition
    16  or  disease  that  (1)(A) is currently or has been subject to a research

    17  study by the  National  Institutes  of  Health  Rare  Diseases  Clinical
    18  Research  Network; or (B) affects fewer than two hundred thousand United
    19  States residents per year; and (2) for which  there  does  not  exist  a
    20  standard  health  service  or  procedure covered by the health care plan
    21  that is more clinically beneficial than the requested health service  or
    22  treatment.  A  physician,  other  than the insured's treating physician,
    23  shall certify in writing that the condition is a rare disease as defined
    24  in this subsection. The certifying physician shall be a licensed, board-
    25  certified or board-eligible physician who specializes  in  the  area  of
    26  practice  appropriate  to  treat the insured's rare disease. The certif-
    27  ication shall provide either: (1) that the  insured's  rare  disease  is
    28  currently or has been subject to a research study by the National Insti-

    29  tutes of Health Rare Diseases Clinical Research Network; or (2) that the
    30  insured's  rare  disease  affects fewer than two hundred thousand United
    31  States residents per year. The certification shall rely on  medical  and
    32  scientific  evidence  to  support the requested health service or proce-
    33  dure, if such evidence exists, and shall include a statement that, based
    34  on the physician's credible experience, there is no  standard  treatment
    35  that  is likely to be more clinically beneficial to the insured than the
    36  requested health service or procedure and the requested  health  service
    37  or  procedure  is  likely to benefit the insured in the treatment of the
    38  insured's rare disease and that such benefit to  the  insured  outweighs
    39  the  risks of such health service or procedure. The certifying physician
    40  shall disclose any material financial or professional relationship  with

    41  the provider of the requested health service or procedure as part of the
    42  application  for  external appeal of denial of a rare disease treatment.
    43  If the provision of the requested  health  service  or  procedure  at  a
    44  health  care facility requires prior approval of an institutional review
    45  board, an insured or insured's designee shall also submit such  approval
    46  as part of the external appeal application.
    47    §  53.  Subparagraphs  (A) and (B) of paragraph 1 of subsection (b) of
    48  section 4910 of the insurance law, as added by chapter 586 of  the  laws
    49  of 1998, are amended to read as follows:
    50    (A)  the  insured  has  had coverage of the health care service, which
    51  would otherwise be a covered benefit  under  a  subscriber  contract  or
    52  governmental  health  benefit  program, denied on appeal, in whole or in
    53  part, pursuant to title one of this article on  the  grounds  that  such

    54  health  care  service  [is  not  medically  necessary] does not meet the
    55  health care plan's requirements for medical necessity,  appropriateness,

        S. 5800                            36
 
     1  health  care setting, level of care, or effectiveness of a covered bene-
     2  fit, and
     3    (B)  the  health  care plan has rendered a final adverse determination
     4  with respect to such health care  service  or  both  the  plan  and  the
     5  insured have jointly agreed to waive any internal appeal, or the insured
     6  is  deemed to have exhausted or is not required to complete any internal
     7  appeal pursuant to section 2719 of the Public  Health  Service  Act,  42
     8  U.S.C. § 300gg-19; or
     9    §  54. Subparagraphs (A), (B) and (C) of paragraph 2 of subsection (b)

    10  of section 4910 of the insurance law, subparagraph (A) as added by chap-
    11  ter 586 of the laws of 1998, and subparagraphs (B) and (C) as amended by
    12  chapter 237 of the laws of 2009, are amended to read as follows:
    13    (A) the insured has had coverage of a health care  service  denied  on
    14  the basis that such service is experimental or investigational, and such
    15  denial  has  been  upheld  on  appeal  under [section four thousand nine
    16  hundred four] title one of this  article,  or  both  the  plan  and  the
    17  insured have jointly agreed to waive any internal appeal, or the insured
    18  is  deemed to have exhausted or is not required to complete any internal
    19  appeal pursuant to section 2719 of the Public  Health  Service  Act,  42
    20  U.S.C. § 300gg-19, and

    21    (B)  the  insured's attending physician has certified that the insured
    22  has a [life-threatening or disabling] condition or disease (a) for which
    23  standard health services or procedures have been ineffective or would be
    24  medically inappropriate, or (b) for which there does not  exist  a  more
    25  beneficial  standard  health  service or procedure covered by the health
    26  care plan, or (c) for which  there  exists  a  clinical  trial  or  rare
    27  disease treatment, and
    28    (C)  the insured's attending physician, who must be a licensed, board-
    29  certified or board-eligible physician qualified to practice in the  area
    30  of  practice  appropriate  to  treat  the insured's [life-threatening or
    31  disabling] condition or disease, must  have  recommended  either  (a)  a
    32  health  service  or procedure (including a pharmaceutical product within

    33  the meaning of subparagraph (B) of paragraph two of  subsection  (e)  of
    34  section  four  thousand nine hundred of this article) that, based on two
    35  documents from the available medical and scientific evidence, is  likely
    36  to  be  more  beneficial to the insured than any covered standard health
    37  service or procedure or, in the case of a rare  disease,  based  on  the
    38  physician's  certification  required by subsection (g-7) of section four
    39  thousand nine hundred of this article and such  other  evidence  as  the
    40  insured, the insured's designee or the insured's attending physician may
    41  present,  that  the  requested  health service or procedure is likely to
    42  benefit the insured in the treatment of the insured's rare  disease  and
    43  that  such  benefit  to  the  insured outweighs the risks of such health
    44  service or procedure; or (b) a clinical trial for which the  insured  is

    45  eligible.  Any physician certification provided under this section shall
    46  include a statement of the evidence relied  upon  by  the  physician  in
    47  certifying his or her recommendation, and
    48    § 55. Subsection (c) of section 4910 of the insurance law, as added by
    49  chapter 586 of the laws of 1998, is amended to read as follows:
    50    (c)  (1)  The  health  care plan may charge the insured a fee of up to
    51  [fifty] twenty-five dollars per external appeal with an annual limit  on
    52  filing  fees  for an insured not to exceed seventy-five dollars within a
    53  single plan year; provided that, in the event the external appeal  agent
    54  overturns the final adverse determination of the plan, such fee shall be
    55  refunded  to the insured. Notwithstanding the foregoing, the health plan

    56  shall not require the enrollee to pay any such fee if the enrollee is  a

        S. 5800                            37
 
     1  recipient  of  medical  assistance or is covered by a policy pursuant to
     2  title one-A of article twenty-five of the public health law.    Notwith-
     3  standing the foregoing, the health plan shall not require the insured to
     4  pay  any  such  fee  if such fee shall pose a hardship to the [enrollee]
     5  insured as determined by the plan.
     6    (2) The health care plan may charge the insured's health care provider
     7  a fee of up to fifty dollars per external  appeal,  other  than  for  an
     8  external  appeal  requested  pursuant  to  paragraph  two  or  three  of
     9  subsection (d) of section four thousand nine hundred  fourteen  of  this

    10  article; provided that, in the event the external appeal agent overturns
    11  the  final adverse determination of the plan, such fee shall be refunded
    12  to the insured's health care provider.
    13    § 56. Paragraphs 4 and 5 of subsection (b)  of  section  4912  of  the
    14  insurance  law, as added by chapter 586 of the laws of 1998, are amended
    15  and a new paragraph 6 is added to read as follows:
    16    (4) establish a toll-free telephone service to receive information  on
    17  a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant
    18  to  this  title. Such system shall be capable of accepting, recording or
    19  providing instruction to incoming  telephone  calls  during  other  than
    20  normal business hours[, and];
    21    (5) develop procedures to ensure that:
    22    (i)  appropriate  personnel  are  reasonably  accessible not less than

    23  forty hours per week during normal business  hours  to  discuss  patient
    24  care and to allow response to telephone requests, and
    25    (ii)  response to accepted or recorded messages shall be made not less
    26  than one business day after the date on which the call was  received[.];
    27  and
    28    (6)  be  accredited  by  a  nationally  recognized private accrediting
    29  organization.
    30    § 57. Paragraphs 1 and 3 of subsection (b)  of  section  4914  of  the
    31  insurance  law,  paragraph 1 as added by chapter 586 of the laws of 1998
    32  and paragraph 3 as amended by chapter 237  of  the  laws  of  2009,  are
    33  amended to read as follows:
    34    (1)  The  insured shall have [forty-five days] four months to initiate
    35  an external appeal after the insured receives  notice  from  the  health

    36  care  plan,  or such plan's utilization review agent if applicable, of a
    37  final adverse determination or denial, or after both the  plan  and  the
    38  [enrollee]  insured have jointly agreed to waive any internal appeal, or
    39  after the insured is deemed to have exhausted  or  is  not  required  to
    40  complete  any  internal  appeal  pursuant  to section 2719 of the Public
    41  Health  Service  Act,  42  U.S.C.  §  300gg-19.  Where  applicable,  the
    42  insured's health care provider shall have forty-five days to initiate an
    43  external appeal after the insured or the insured's health care provider,
    44  as applicable, receives notice from the health care plan, or such plan's
    45  utilization review agent if applicable, of a final adverse determination

    46  or  denial or after both the plan and the insured have jointly agreed to
    47  waive any internal appeal. Such request shall be in writing  in  accord-
    48  ance with the instructions and in such form prescribed by subsection (e)
    49  of  this  section.  The  insured, and the insured's health care provider
    50  where applicable,  shall  have  the  opportunity  to  submit  additional
    51  documentation  with  respect to such appeal to the external appeal agent
    52  within [such forty-five-day period] the applicable  time  period  above;
    53  provided  however  that  when  such  documentation represents a material
    54  change from the documentation upon which the  utilization  review  agent
    55  based  its adverse determination or upon which the health plan based its

        S. 5800                            38
 

     1  denial, the health plan shall have three business days to consider  such
     2  documentation and amend or confirm such adverse determination.
     3    (3)  Notwithstanding  the provisions of paragraphs one and two of this
     4  subsection, if the insured's attending physician states that a delay  in
     5  providing  the  health  care  service  would pose an imminent or serious
     6  threat to the health of the insured, or if the insured is entitled to an
     7  expedited external appeal pursuant to section 2719 of the Public  Health
     8  Service  Act,  42  U.S.C.    §  300gg-19,  the  external appeal shall be
     9  completed within [three days] no more  than  seventy-two  hours  of  the
    10  request  therefor and the external appeal agent shall make every reason-
    11  able attempt to immediately notify the  insured,  the  insured's  health

    12  care  provider  where  appropriate,  and the health plan of its determi-
    13  nation by  telephone  or  facsimile,  followed  immediately  by  written
    14  notification of such determination.
    15    §  58.  Clause  (a) of item (ii) of subparagraph (B) of paragraph 4 of
    16  subsection (b) of section 4914 of the insurance law, as amended by chap-
    17  ter 237 of the laws of 2009, is amended to read as follows:
    18    (a) that the patient costs of the proposed health service or procedure
    19  shall be covered by the health care plan either: when a majority of  the
    20  panel  of  reviewers  determines,  based  upon  review of the applicable
    21  medical and scientific evidence and, in connection with  rare  diseases,
    22  the  physician's  certification  required by subsection (g-7) of section
    23  four thousand nine hundred of this article and such  other  evidence  as

    24  the insured, the insured's designee or the insured's attending physician
    25  may  present  (or  upon confirmation that the recommended treatment is a
    26  clinical trial), the insured's medical record, and any  other  pertinent
    27  information,  that the proposed health service or treatment (including a
    28  pharmaceutical product within the meaning of subparagraph (B)  of  para-
    29  graph  two  of  subsection  (e) of section four thousand nine hundred of
    30  this article) is likely to be more beneficial than any  standard  treat-
    31  ment  or  treatments  for  the insured's [life-threatening or disabling]
    32  condition or disease or, for rare diseases, that  the  requested  health
    33  service  or  procedure is likely to benefit the insured in the treatment
    34  of the insured's rare disease and  that  such  benefit  to  the  insured
    35  outweighs the risks of such health service or procedure (or, in the case

    36  of  a  clinical trial, is likely to benefit the insured in the treatment
    37  of the insured's condition or disease); or when  a  reviewing  panel  is
    38  evenly  divided  as to a determination concerning coverage of the health
    39  service or procedure, or
    40    § 59. Section 4403 of the public health law is amended by adding a new
    41  subdivision 7 to read as follows:
    42    7. A health maintenance organization that  requires  or  provides  for
    43  designation  by  an  enrollee  of  a participating primary care provider
    44  shall permit the enrollee to designate any  participating  primary  care
    45  provider  who is available to accept such individual, and in the case of
    46  a child, shall permit the enrollee to designate a physician  (allopathic
    47  or  osteopathic)  who  specializes  in pediatrics as the child's primary

    48  care provider if such provider participates in the network of the health
    49  maintenance organization.
    50    § 60. Subdivisions 1 and 2 of section 4406-b of the public health law,
    51  as added by chapter 645 of the laws of 1994,  are  amended  to  read  as
    52  follows:
    53    1.  The  health  maintenance  organization  shall  not  limit a female
    54  enrollee's direct access to primary and preventive obstetric and gyneco-
    55  logic services, including annual examinations, care resulting from  such
    56  annual examinations, and treatment of acute gynecologic conditions, from

        S. 5800                            39
 
     1  a qualified provider of such services of her choice from within the plan
     2  [to  less  than two examinations annually for such services] or [to] for

     3  any care related to a pregnancy[. In addition,  the  health  maintenance
     4  organization  shall  not  limit  direct access to primary and preventive
     5  obstetric and gynecologic services required as a result of  such  annual
     6  examinations or as a result of an acute gynecologic condition], provided
     7  that:  (a) such qualified provider discusses such services and treatment
     8  plan with the enrollee's primary care practitioner  in  accordance  with
     9  the  requirements  of  the health maintenance organization; and (b) such
    10  qualified provider agrees to adhere to the health maintenance  organiza-
    11  tion's  policies  and  procedures,  including  any applicable procedures
    12  regarding referrals and obtaining prior authorization for services other

    13  than obstetric and  gynecologic  services  rendered  by  such  qualified
    14  provider,  and  agrees  to provide services pursuant to a treatment plan
    15  (if any) approved by the health maintenance organization.
    16    2. A health maintenance organization  shall  treat  the  provision  of
    17  obstetric  and  gynecologic  care, and the ordering of related obstetric
    18  and gynecologic items  and  services,  pursuant  to  the  direct  access
    19  described  in  subdivision one of this section by a participating quali-
    20  fied provider of such services, as the authorization of the primary care
    21  provider.
    22    3. It shall be the duty of the administrative officer or other  person
    23  in  charge of each health maintenance organization to advise each female

    24  enrollee, in writing, of the provisions of this section.
    25    § 61. Subdivision 3 of section 4900 of the public health law, as added
    26  by chapter 705 of the laws of 1996, is amended to read as follows:
    27    3. "Emergency condition" means a medical or behavioral condition, [the
    28  onset of which is sudden,] that manifests itself by  acute  symptoms  of
    29  sufficient  severity, including severe pain, such that a prudent layper-
    30  son, possessing an average  knowledge  of  medicine  and  health,  could
    31  reasonably  expect  the absence of immediate medical attention to result
    32  in (a) placing the health of the person afflicted with such condition in
    33  serious jeopardy, or in the case of a behavioral condition, placing  the
    34  health of such person or others in serious jeopardy; (b) serious impair-

    35  ment  to  such person's bodily functions; (c) serious dysfunction of any
    36  bodily organ or part of such person; [or] (d) serious  disfigurement  of
    37  such  person;  or (e) a condition described in clause (i), (ii) or (iii)
    38  of section 1867(e)(1)(A) of the Social Security Act.
    39    § 62. Subdivision 7-g of section 4900 of the  public  health  law,  as
    40  added by chapter 237 of the laws of 2009, is amended to read as follows:
    41    7-g.  "Rare disease" means a [life threatening or disabling] condition
    42  or disease that (1)(A) is currently or has been subject  to  a  research
    43  study  by  the  National  Institutes  of  Health  Rare Diseases Clinical
    44  Research Network or (B) affects fewer than two hundred  thousand  United
    45  States  residents  per  year,  and  (2) for which there does not exist a

    46  standard health service or procedure covered by  the  health  care  plan
    47  that  is more clinically beneficial than the requested health service or
    48  treatment. A physician, other than the  enrollee's  treating  physician,
    49  shall certify in writing that the condition is a rare disease as defined
    50  in this subsection. The certifying physician shall be a licensed, board-
    51  certified  or  board-eligible  physician  who specializes in the area of
    52  practice appropriate to treat the enrollee's rare disease.  The  certif-
    53  ication  shall  provide  either:  (1) that the insured's rare disease is
    54  currently or has been subject to a research study by the National Insti-
    55  tutes of Health Rare Diseases Clinical Research Network; or (2) that the
    56  insured's rare disease affects fewer than two  hundred  thousand  United

        S. 5800                            40
 

     1  States  residents  per year. The certification shall rely on medical and
     2  scientific evidence to support the requested health  service  or  proce-
     3  dure, if such evidence exists, and shall include a statement that, based
     4  on  the  physician's credible experience, there is no standard treatment
     5  that is likely to be more clinically beneficial to the enrollee than the
     6  requested health service or procedure and the requested  health  service
     7  or  procedure  is likely to benefit the enrollee in the treatment of the
     8  enrollee's rare disease and that such benefit to the enrollee  outweighs
     9  the risks of such health service or procedure.  The certifying physician
    10  shall  disclose any material financial or professional relationship with
    11  the provider of the requested health service or procedure as part of the
    12  application for external appeal of denial of a rare  disease  treatment.

    13  If  the  provision  of  the  requested  health service or procedure at a
    14  health care facility requires prior approval of an institutional  review
    15  board,  an  enrollee  or  enrollee's  designee  shall  also  submit such
    16  approval as part of the external appeal application.
    17    § 63. Subparagraphs (i) and (ii) of paragraph (a) of subdivision 2  of
    18  section  4910  of  the public health law, as added by chapter 586 of the
    19  laws of 1998, are amended to read as follows:
    20    (i) the enrollee has had coverage of  a  health  care  service,  which
    21  would  otherwise  be  a  covered  benefit under a subscriber contract or
    22  governmental health benefit program, denied on appeal, in  whole  or  in
    23  part,  pursuant  to  title  one of this article on the grounds that such
    24  health care service [is not  medically  necessary]  does  not  meet  the

    25  health  care plan's requirements for medical necessity, appropriateness,
    26  health care setting, level of care, or effectiveness of a covered  bene-
    27  fit, and
    28    (ii)  the  health care plan has rendered a final adverse determination
    29  with respect to such health care service or both the plan and the enrol-
    30  lee have jointly agreed to waive any internal appeal, or the enrollee is
    31  deemed to have exhausted or is not required  to  complete  any  internal
    32  appeal  pursuant  to  section  2719 of the Public Health Service Act, 42
    33  U.S.C. § 300gg-19; or
    34    § 64. Subparagraphs (i), (ii) and (iii) of paragraph (b)  of  subdivi-
    35  sion  2  of  section  4910 of the public health law, subparagraph (i) as
    36  added by chapter 586 of the laws of 1998,  and  subparagraphs  (ii)  and

    37  (iii) as amended by chapter 237 of the laws of 2009, are amended to read
    38  as follows:
    39    (i)  the  enrollee has had coverage of a health care service denied on
    40  the basis that such service is experimental or investigational, and such
    41  denial has been upheld on appeal under title one  of  this  article,  or
    42  both the plan and the enrollee have jointly agreed to waive any internal
    43  appeal,  or  the enrollee is deemed to have exhausted or is not required
    44  to complete any internal appeal pursuant to section 2719 of the  federal
    45  Public Health Service Act, 42 U.S.C. § 300gg-19, and
    46    (ii)  the enrollee's attending physician has certified that the enrol-
    47  lee has a [life-threatening or disabling] condition or disease  (a)  for
    48  which  standard  health  services or procedures have been ineffective or

    49  would be medically inappropriate, or (b) for which there does not  exist
    50  a  more  beneficial  standard health service or procedure covered by the
    51  health care plan, or (c) for which there exists a clinical trial or rare
    52  disease treatment, and
    53    (iii) the enrollee's attending physician,  who  must  be  a  licensed,
    54  board-certified or board-eligible physician qualified to practice in the
    55  area  of  practice appropriate to treat the enrollee's [life threatening
    56  or disabling] condition or disease, must have recommended either  (a)  a

        S. 5800                            41
 
     1  health  service  or procedure (including a pharmaceutical product within
     2  the meaning of subparagraph (B) of paragraph (b) of subdivision five  of
     3  section forty-nine hundred of this article) that, based on two documents

     4  from the available medical and scientific evidence, is likely to be more
     5  beneficial  to  the enrollee than any covered standard health service or
     6  procedure or, in the case of a rare disease, based  on  the  physician's
     7  certification  required  by  subdivision  seven-g  of section forty-nine
     8  hundred of this article and such other evidence  as  the  enrollee,  the
     9  enrollee's  designee  or the enrollee's attending physician may present,
    10  that the requested health service or procedure is likely to benefit  the
    11  enrollee  in  the treatment of the enrollee's rare disease and that such
    12  benefit to the enrollee outweighs the risks of such  health  service  or
    13  procedure;  or  (b) a clinical trial for which the enrollee is eligible.
    14  Any physician certification provided under this section shall include  a
    15  statement of the evidence relied upon by the physician in certifying his

    16  or her recommendation, and
    17    § 65. Subdivision 3 of section 4910 of the public health law, as added
    18  by chapter 586 of the laws of 1998, is amended to read as follows:
    19    3.  (a)  The  health  care plan may charge the enrollee a fee of up to
    20  [fifty] twenty-five dollars per external appeal with an annual limit  on
    21  filing  fees for an enrollee not to exceed seventy-five dollars within a
    22  single plan year; provided that, in the event the external appeal  agent
    23  overturns the final adverse determination of the plan, such fee shall be
    24  refunded to the enrollee. Notwithstanding the foregoing, the health plan
    25  shall  not require the enrollee to pay any such fee if the enrollee is a
    26  recipient of medical assistance or is covered by a  policy  pursuant  to

    27  title one-A of article twenty-five of this chapter.  Notwithstanding the
    28  foregoing,  the  health  plan  shall not require the enrollee to pay any
    29  such fee if such fee shall pose a hardship to the enrollee as determined
    30  by the plan.
    31    (b) The health care plan may charge the enrollee's health care provid-
    32  er a fee of up to fifty dollars per external appeal, other than  for  an
    33  external  appeal  requested pursuant to paragraph (b) or (c) of subdivi-
    34  sion four of  section  forty-nine  hundred  fourteen  of  this  article;
    35  provided  that,  in  the  event  the external appeal agent overturns the
    36  final adverse determination of the plan, such fee shall be  refunded  to
    37  the enrollee's health care provider.
    38    §  66.  Paragraphs (d) and (e) of subdivision 2 of section 4912 of the

    39  public health law, as added by chapter 586 of  the  laws  of  1998,  are
    40  amended and a new paragraph (f) is added to read as follows:
    41    (d)  establish a toll-free telephone service to receive information on
    42  a 24-hour-a-day 7-day-a-week basis relating to external appeals pursuant
    43  to this title. Such system shall be capable of accepting,  recording  or
    44  providing  instruction  to  incoming  telephone  calls during other than
    45  normal business hours[, and];
    46    (e) develop procedures to ensure that:
    47    (i) appropriate personnel are  reasonably  accessible  not  less  than
    48  forty  hours  per  week  during normal business hours to discuss patient
    49  care and to allow response to telephone requests, and
    50    (ii) response to accepted or recorded messages shall be made not  less
    51  than  one business day after the date on which the call was received[.];

    52  and
    53    (f) be accredited  by  a  nationally  recognized  private  accrediting
    54  organization.
    55    §  67.  Paragraphs (a) and (c) of subdivision 2 of section 4914 of the
    56  public health law, paragraph (a) as added by chapter 586 of the laws  of

        S. 5800                            42
 
     1  1998  and  paragraph  (c) as amended by chapter 237 of the laws of 2009,
     2  are amended to read as follows:
     3    (a)  The enrollee shall have [forty-five days] four months to initiate
     4  an external appeal after the enrollee receives notice  from  the  health
     5  care  plan,  or such plan's utilization review agent if applicable, of a
     6  final adverse determination or denial or after both  the  plan  and  the
     7  enrollee  have jointly agreed to waive any internal appeal, or after the

     8  enrollee is deemed to have exhausted or is not required to complete  any
     9  internal  appeal  pursuant  to section 2719 of the Public Health Service
    10  Act, 42 U.S.C. § 300gg-19. Where applicable, the enrollee's health  care
    11  provider shall have forty-five days to initiate an external appeal after
    12  the  enrollee  or  the  enrollee's  health care provider, as applicable,
    13  receives notice from the health care plan, or  such  plan's  utilization
    14  review  agent  if applicable, of a final adverse determination or denial
    15  or after both the plan and the enrollee have jointly agreed to waive any
    16  internal appeal. Such request shall be in writing in accordance with the
    17  instructions and in such form prescribed by  subdivision  five  of  this

    18  section.  The  enrollee,  and  the enrollee's health care provider where
    19  applicable, shall have the opportunity to submit  additional  documenta-
    20  tion  with  respect  to  such appeal to the external appeal agent within
    21  [such forty-five-day period] the applicable time period above;  provided
    22  however  that  when such documentation represents a material change from
    23  the documentation upon which the  utilization  review  agent  based  its
    24  adverse  determination  or  upon which the health plan based its denial,
    25  the health plan shall have three business days to consider such documen-
    26  tation and amend or confirm such adverse determination.
    27    (c) Notwithstanding the provisions of paragraphs (a) and (b)  of  this
    28  subdivision,  if  the enrollee's attending physician states that a delay
    29  in providing the health care service would pose an imminent  or  serious

    30  threat  to the health of the enrollee, or if the enrollee is entitled to
    31  an expedited external appeal pursuant to section  2719  of  the  federal
    32  Public  Health  Service  Act,  42 U.S.C. § 300gg-19, the external appeal
    33  shall be completed within [three days] no more than seventy-two hours of
    34  the request therefor and the external  appeal  agent  shall  make  every
    35  reasonable  attempt  to  immediately notify the enrollee, the enrollee's
    36  health care provider where appropriate,  and  the  health  plan  of  its
    37  determination by telephone or facsimile, followed immediately by written
    38  notification of such determination.
    39    §  68.  Item  1 of clause (ii) of subparagraph (B) of paragraph (d) of
    40  subdivision 2 of section 4914 of the public health law,  as  amended  by

    41  chapter 237 of the laws of 2009, is amended to read as follows:
    42    (1) that the patient costs of the proposed health service or procedure
    43  shall  be covered by the health care plan either: when a majority of the
    44  panel of reviewers determines,  based  upon  review  of  the  applicable
    45  medical  and  scientific evidence and, in connection with rare diseases,
    46  the physician's certification required by subdivision seven-g of section
    47  forty-nine hundred of this article and such other evidence as the enrol-
    48  lee, the enrollee's designee or the enrollee's attending  physician  may
    49  present  (or upon confirmation that the recommended treatment is a clin-
    50  ical trial), the enrollee's medical  record,  and  any  other  pertinent
    51  information,  that the proposed health service or treatment (including a
    52  pharmaceutical product within the meaning of subparagraph (B)  of  para-

    53  graph  (b)  of  subdivision  five  of section forty-nine hundred of this
    54  article) is likely to be more beneficial than any standard treatment  or
    55  treatments  for the enrollee's [life-threatening or disabling] condition
    56  or disease or, for rare diseases, that the requested health  service  or

        S. 5800                            43
 
     1  procedure  is  likely  to  benefit  the enrollee in the treatment of the
     2  enrollee's rare disease and that such benefit to the enrollee  outweighs
     3  the  risks  of  such  health  service or procedure (or, in the case of a
     4  clinical  trial,  is  likely to benefit the enrollee in the treatment of
     5  the enrollee's condition or disease); or when a reviewing panel is even-
     6  ly divided as to a  determination  concerning  coverage  of  the  health
     7  service or procedure, or

     8    § 69. If any provision of this act or the application thereof shall be
     9  held to be invalid, such invalidity shall not affect other provisions of
    10  this act which can be given effect without the invalid provision; and to
    11  that end, the provisions of this act are severable.
    12    § 70. This act shall take effect immediately:
    13    1.  provided,  that  for  policies  renewed  on or after such date but
    14  before September 23, 2011, this act shall take effect upon  the  renewal
    15  date;
    16    2.  provided,  however,  that  sections  eight,  nine,  ten, fourteen,
    17  fifteen, sixteen, seventeen, eighteen, twenty-three,  twenty-six,  twen-
    18  ty-seven, twenty-eight, twenty-nine, thirty, forty, forty-one, forty-two
    19  and  forty-three  of this act shall, with respect to blanket policies of
    20  hospital, medical,  surgical  or  prescription  drug  expense  insurance

    21  covering  students  pursuant  to  subparagraph  (C)  of  paragraph  3 of
    22  subsection (a) of section 4237 of the insurance law, take effect January
    23  1, 2012 and apply to policies issued or renewed on and after such  date;
    24  and
    25    3.  provided,  further,  that  sections fifty-two, fifty-three, fifty-
    26  four,  fifty-five,  fifty-six,  fifty-seven,   fifty-eight,   sixty-two,
    27  sixty-three,  sixty-four,  sixty-five, sixty-six, sixty-seven and sixty-
    28  eight of this act shall take effect on the later of July 1, 2011, or the
    29  date the external appeal requirements of  section  2719  of  the  Public
    30  Health  Service Act, 42 U.S.C. § 300gg-19 are determined to be effective
    31  by the Secretary of Health and Human  Services  and  apply  to  a  final
    32  adverse determination issued on and after such date.
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