Current through Register Vol. 46, No. 39, September 25, 2024
(a) No policy
or certificate shall provide benefits for specified diseases, or for procedures
or treatments unique to specified diseases, and no policy or certificate shall
provide additional benefits for such specified diseases or procedures, unless
the policy or certificate meets the standards set forth in section
52.15 or section
52.22 of this Part.
(b) No policy shall provide a return of
premium or cash value benefit, except return of unearned premium upon
termination or suspension of coverage, retroactive waiver of premium paid
during disability, payment of dividends on participating policies, experience
rating refunds, nonforfeiture values permitted for long-term care insurance,
nursing home and home care insurance or nursing home insurance only, or a
return of premium benefit upon death permitted for long-term care insurance,
nursing home insurance only, home care insurance only, or nursing home and home
care insurance. This prohibition applies to an accidental death benefit where
the amount of the benefit equals the total premium paid to date of
death.
(c) No policy shall limit or
exclude coverage by type of illness, accident, treatment or medical condition,
except as follows:
(1) preexisting conditions
or diseases, as defined in section
52.2(u) of this
Part or section
3232 or
4318 of the
Insurance Law, except for congenital anomalies of a covered dependent child;
subject to limitations set forth in subdivision (f) of this section, sections
52.17(a)(27)-(28),
52.18(a)(5) and
52.20 of this Part;
(2) mental or emotional disorders, alcoholism
and drug addiction, except that coverage must be made available or provided
pursuant to section
52.7 of this Part and sections
3221 and
4303 of the
Insurance Law. Medicare supplement insurance issued pursuant to section
52.11 of this Part and Part 58 of
this Title shall not include limitations or exclusions which are more
restrictive than those of Medicare for this type of benefit;
(3) pregnancy, except to the extent coverage
is required pursuant to sections
3216,
3221,
3232,
4303, and
4318 of the
Insurance Law, and except for complications of pregnancy as defined in section
52.2(e) of this
Part, other than for policies defined in section
52.8 of this Part;
(4) illness, accident, treatment or medical
condition arising out of:
(i) war or act of
war (whether declared or undeclared); participation in a felony, riot or
insurrection; service in the Armed Forces or units auxiliary thereto;
(ii) suicide, attempted suicide or
intentionally self-inflicted injury;
(iii) aviation, other than as a fare-paying
passenger on a scheduled or charter flight operated by a scheduled airline;
and
(iv) with respect to blanket
insurance, interscholastic sports;
(5) cosmetic surgery, except that cosmetic
surgery shall not include reconstructive surgery when such service is
incidental to or follows surgery resulting from trauma, infection or other
diseases of the involved part, and reconstructive surgery because of congenital
disease or anomaly of a covered dependent child which has resulted in a
functional defect. However, if the policy provides hospital, surgical or
medical expense coverage, including a policy issued by a health maintenance
organization, then coverage and determinations with respect to cosmetic surgery
must be provided pursuant to Part 56 of this Title (Regulation 183);
(6) foot care, in connection with corns,
calluses, flat feet, fallen arches, weak feet, chronic foot strain or
symptomatic complaints of the feet; unless the policy is issued as Medicare
supplement insurance pursuant to section
52.11 of this Part and Part 58 of
this Title, in which case the policy shall not include limitations or
exclusions more restrictive than those of Medicare for this type of
benefit;
(7) care in connection
with the detection and correction by manual or mechanical means of structural
imbalance, distortion or subluxation in the human body for purposes of removing
nerve interference and the effects thereof, where such interference is the
result of or related to distortion, misalignment or subluxation of or in the
vertebral column; unless the policy is issued as Medicare supplement insurance
pursuant to section
52.11 of this Part and Part 58 of
this Title, in which case the policy shall not include limitations or
exclusions more restrictive than those of Medicare for this type of
benefit;
(8) treatment provided in
a government hospital; benefits provided under Medicare or other governmental
program (except Medicaid), any State or Federal workers' compensation,
employers' liability or occupational disease law; benefits to the extent
provided for any loss or portion thereof for which mandatory automobile
no-fault benefits are recovered or recoverable; services rendered and
separately billed by employees of hospitals, laboratories or other
institutions; services performed by a member of the covered person's immediate
family; and services for which no charge is normally made;
(9) dental care or treatment, except for such
care or treatment due to accidental injury to sound natural teeth within 12
months of the accident and except for dental care or treatment necessary due to
congenital disease or anomaly;
(10)
eyeglasses, hearing aids, and examination for the prescription or fitting
thereof;
(11) rest cures, custodial
care and transportation, unless the policy is issued as Medicare supplement
insurance pursuant to section
52.11 of this Part and Part 58 of
this Title, in which case the policy shall not include limitations or
exclusions more restrictive than those of Medicare for this type of benefit;
and
(12) coverage while the insured
is outside the United States, its possessions or the countries of Canada and
Mexico.
(d) No policy
shall contain provisions establishing a probationary or similar period longer
than the following:
(1) for all specified
conditions: 30 days;
(2) for
inception of pregnancy, except where otherwise specifically prescribed by
statute: 30 days; and
(3) for
accidents: none.
This subdivision shall not apply to benefits for dental,
hearing or vision care.
(e) Except with respect to Medicare
supplement insurance, as defined in section
52.11 of this Part and Part 58 of
this Title, nothing contained in subdivisions (c) and (d) of this section shall
preclude:
(1) the use of a nonduplication of
coverage or coordination of benefit provision; or
(2) unless otherwise provided by law, waivers
to exclude, limit or reduce coverage or benefits for specifically named or
described disease, physical condition or extra-hazardous activity, as defined
in section
52.2(i) of this
Part, as an alternative to refusal to issue, renew or reinstate coverage.
Where waivers are required as a condition of issuance,
renewal or reinstatement, signed acceptance by the insured is required unless
on initial issuance the full text of the exclusion is contained either on the
first page or specification page of the policy. Waivers to exclude, limit or
reduce coverage or benefits for specifically named or described preexisting
diseases or physical conditions shall not be used in Medicare supplement
insurance.
(f)
No group or blanket medical expense insurance policy insuring 300 or more
persons, excluding dependents, shall contain a provision which excludes or
limits coverage for preexisting conditions for any person who elects coverage
during the first 30 days of eligibility. This provision shall not apply to
blanket insurance where enrollment for the coverage is voluntary, to dental
insurance, to insurance written under section
4235 (c)(1)(H) (K) (L) and
(M) of the Insurance Law or to the extent
that insurance written under section
4235 (c)(1)(B) and
(D) of the Insurance Law insures employees of
an employer with less than 300 employees.
(g) Except as provided for in subdivision (c)
of this section, and coverages in effect after eligibility for Medicare, no
policy shall set more than a single maximum benefit limit for any class of
covered persons in each of the following categories of services provided by a
hospital:
(1) hospital services other than
room and board; and
(2) outpatient
services.
(h) No
community-rated policy issued by an article 43 corporation, other than a policy
providing benefits through a health maintenance organization or its equivalent,
and no individual policy, as defined in section
52.2(n) of this
Part, shall provide benefits which duplicate benefits recoverable under
mandatory automobile no-fault insurance policies unless such benefits are
contained in a rider purchased at the option of the contract holder at an
appropriate premium.
(i) The terms
Medicare supplement, Medigap, Medicare Wrap-Around and words of similar import
shall not be used unless the policy is issued or amended to comply with section
52.11 of this Part and Part 58 of
this Title.
(j) The terms long term
care and custodial care and words of similar import shall not be used in
describing benefits unless the policy is issued or amended to comply with
section 52.12 or
52.13 of this Part.
(k) Any application for a policy of limited
benefits health insurance as defined in section
52.10 of this Part and any such
policy, when offered to persons who are 65 years of age or older, must include
the following notice:
(1) The application
form shall incorporate immediately above the applicant's signature in bold
print at least four points greater than the largest print used in the
application, excluding the company name, logo and address, the following
statement only:
The coverage applied for provides limited benefits health
insurance only. This coverage does not meet the minimum requirements for
Medicare supplement, long term care insurance, nursing home insurance only,
home care insurance only, or nursing home and home care insurance in the state
of New York. Purchase of this coverage may be unnecessary if you already have
or intend to purchase Medicare supplement insurance or long term care
insurance.
(2) The policy
shall incorporate into the top quarter of the first page in bold print at least
four points greater than the largest print used in the policy, excluding the
company name, logo and address, the following statement only:
This policy provides limited benefits health insurance
only. This coverage does not meet the minimum requirements for Medicare
supplement, long-term care insurance, nursing home insurance only, home care
insurance only, or nursing home and home care insurance in the state of New
York. Purchase of this coverage may be unnecessary if you already have or
intend to purchase Medicare supplement insurance or long term care
insurance.
(l)
No policy or certificate shall provide benefits for custodial care services
unless that policy or certificate also provides insurance which meets the
definition contained in section
52.11,
52.12 or
52.13 of this Part. For purposes
of this section custodial care services means help in transferring, eating,
dressing, bathing, toileting, and other such related activities.
(m)
(1)
Pursuant to sections 4322(b-1) and 4326(d-1), no health maintenance
organization or insurer shall issue a standardized individual enrollee direct
payment contract issued pursuant to section
4321 or section
4322 of the
Insurance Law, or a standardized health insurance contract for qualifying small
employers and individuals issued pursuant to section
4326 of the
Insurance Law, that provides coverage for drugs, procedures or supplies for the
treatment of erectile dysfunction when provided to, or prescribed for use by, a
person who is required to register as a sex offender pursuant to article 6-C of
the Correction Law.
(2) Every
notice of denial of coverage issued by a health maintenance organization or
insurer pursuant to this subdivision shall advise the enrollee how to obtain
additional information concerning the denial and the appeal process to
challenge the denial. Use of a health maintenance organization's or insurer's
existing grievance procedures shall be deemed sufficient to comply with the
appeal requirements of this subdivision. Every such notice of denial shall also
advise the enrollee that if the enrollee believes that he has been improperly
placed on the registry of sex offenders maintained by the New York State
Division of Criminal Justice Services, the enrollee should contact the
division. The notice shall include the mailing address, phone number and web
address of the division.
(3)
Coverage of all drugs, procedures and supplies for the treatment of erectile
dysfunction may be subject to prior determination of an enrollee's status under
article 6-C of the Correction Law by a health maintenance organization or
insurer for the purpose of implementing this subdivision.
(4) Nothing in this subdivision shall
preclude a health maintenance organization or insurer from conducting
utilization review on claims for coverage of drugs, procedures and supplies on
behalf of an enrollee determined not to be a person required to register as a
sex offender.
(5) Prior to
obtaining access from the department of insurance to the registry information
of sex offenders obtained from the New York State Division of Criminal Justice
Services, a health maintenance organization or insurer shall execute a
nondisclosure statement and authorization form as prescribed by the
superintendent. The nondisclosure statement and authorization form shall be
signed by an authorized officer of the health maintenance organization or
insurer and shall contain the names of the persons in the employ of the health
maintenance organization or insurer who are authorized to receive the
information. By signing the form the authorized officer certifies that:
(i) the named employees of the health
maintenance organization or insurer are authorized to receive information from
the department of insurance regarding persons required to register as sex
offenders;
(ii) the health
maintenance organization or insurer has developed and implemented
administrative, technical and physical safeguards to protect the security,
confidentiality, and integrity of the information obtained pursuant to this
subdivision, in accordance with Part 421 of this Title (Regulation 173),
including but not limited to safeguards to ensure that such information will
only be disclosed by the named employees to other persons in the employ of the
health maintenance organization or insurer who are directly involved in
approving or disapproving reimbursement or coverage for erectile dysfunction
drugs, procedures and supplies and that no person receiving such information
shall redisclose such information except to other persons in the employ of the
health maintenance organization or insurer who are directly involved in
approving or disapproving reimbursement or coverage for erectile dysfunction
drugs, procedures and supplies; and
(iii) the health maintenance organization or
insurer will promptly notify the department of insurance of any relevant
changes of persons in the employ of the health maintenance organization or
insurer who are authorized to receive such information.
(n)
(1) As used in this subdivision:
(i) Mental health professional means a person
subject to the provisions of Education Law Article 131, 153, 154, or 163; or
any other person designated as a mental health professional pursuant to law,
rule, or regulation.
(ii)
Conversion therapy:
(a) means any practice by
a mental health professional that seeks to change an individual's sexual
orientation or gender identity, including efforts to change behaviors, gender
expressions, or to eliminate or reduce sexual or romantic attractions or
feelings toward individuals of the same sex.
(b) Conversion therapy shall not include
counseling or therapy for an individual who is seeking to undergo a gender
transition or who is in the process of undergoing a gender transition, that
provides acceptance, support, and understanding of an individual or the
facilitation of an individual's coping, social support, and identity
exploration and development, including sexual orientation-neutral interventions
to prevent or address unlawful conduct or unsafe sexual practices, provided
that the counseling or therapy does not seek to change sexual orientation or
gender identity.
(2) No policy or certificate shall provide
coverage for conversion therapy rendered by a mental health professional to an
individual under the age of 18 years
(o)
(1) No policy delivered or
issued for delivery in this State that provides hospital, surgical, or medical
expense coverage shall limit or exclude coverage for abortions that are
medically necessary. Coverage for in-network abortions that are medically
necessary shall not be subject to copayments, or coinsurance, or annual
deductibles, unless the policy is a high deductible health plan as defined in
section 223(c)(2) of the Internal
Revenue Code in which case coverage for medically necessary abortions may be
subject to the plan's annual deductible.
(2) Notwithstanding any other provision of this Part, a group or
blanket policy that provides hospital, surgical, or medical expense coverage
delivered or issued for delivery in this State to a religious employer may
exclude coverage for medically necessary abortions only if the insurer:
(i) obtains an annual certification from the
group or blanket policyholder or contract holder that the policyholder or
contract holder is a religious employer and that the religious employer
requests a contract without coverage for medically necessary
abortions;
(ii) issues a rider to
each certificate holder (i.e., primary insured) at no premium to be charged to
the certificate holder (i.e., primary insured) or religious employer for the
rider, that provides coverage for medically necessary abortions subject to the
same rules as would have been applied to the same category of treatment in the
policy issued to the religious employer. The rider must clearly and
conspicuously specify that the religious employer does not administer medically
necessary abortion benefits, but that the insurer is issuing a rider for
coverage of medically necessary abortions, and shall provide the insurer's
contact information for questions; and
(iii) provides notice of the issuance of the policy and rider to
the superintendent in a form and manner acceptable to the
superintendent.
