Current through Register Vol. 46, No. 39, September 25, 2024
(a) Every
individual and small group accident and health insurance policy that provides
hospital, surgical, or medical expense coverage and is not a grandfathered
health plan, and every student accident and health insurance policy shall
provide coverage of at least the following essential health benefits:
(1) ambulatory patient services, such as
office visits, ambulatory surgical services, dialysis, radiology services,
chemotherapy, infertility treatment, abortion services, hospice care, and
diabetic equipment, supplies and self-management education;
(2) emergency services, such as emergency
room services, urgent care services, and ambulance services;
(3) hospitalization, such as preadmission
testing, inpatient physician and surgical services, hospital care, skilled
nursing facility care, and hospice care;
(4) maternity and newborn care, such as
delivery, prenatal a nd postnatal care, and breastfeeding education and
equipment;
(5) mental health and
substance use disorder services, including behavioral health treatment, such as
inpatient and outpatient services for the diagnosis and treatment of mental,
nervous and emotional disorders including maternal depression, screening,
diagnosis and treatment for autism spectrum disorder, and inpatient and
outpatient services for the diagnosis and treatment of substance use disorder;
(6) prescription drugs, such as
coverage for generic, brand name and specialty drugs, enteral formulas,
contraceptive drugs and devices, abortifacient drugs, and orally administered
anticancer medication;
(7)
rehabilitative and habilitative services and devices, such as durable medical
equipment, medical supplies, prosthetic devices, hearing aids, chiropractic
care, physical therapy, occupational therapy, speech therapy, and home health
care;
(8) laboratory services,
such as diagnostic testing;
(9)
preventive and wellness services and chronic disease management, such as well
child visits, immunizations, mammography, gynecological exams including
cervical cytology screening, bone density measurements or testing, and prostate
cancer screening; and
(10)
pediatric services, including oral and vision care, such as preventive and
routine pediatric vision and dental care, and prescription lenses and frames.
(b) The scope of the
minimum benefits covered as essential health benefits pursuant to subdivision
(a) of this section shall be equal to the benefits provided by the benchmark
plan selected by the superintendent as the New York Benchmark Plan in
accordance with this section.
(c)
Subject to subdivisions (d) and (e) of this section, the superintendent may
select the New York Benchmark Plan in consultation with the commissioner of
health from any of the following plans:
(1)
Small group market health plan. The largest health plan by enrollment in any of
the three largest small group insurance products by enrollment in the small
group market in this state;
(2)
State employee health benefit plan. Any of the largest three employee health
benefit plan options by enrollment offered and generally available to state
employees in this state;
(3) FEHBP
plan. Any of the largest three national Federal Employees Health Benefits
Program (FEHBP) plan options by aggregate enrollment that is offered to all
health-benefits-eligible federal employees under
5 U.S.C. section
8903;
(4) HMO. The coverage plan with the largest
insured commercial non-Medicaid enrollment offered by a health maintenance
organization operating in this State; or
(5) Any other plan identified by the
superintendent as a typical employer plan providing the coverage of essential
health benefits required by this section:
(d)
(1) In
order to be eligible to be selected as the New York Benchmark Plan, a plan
shall provide coverage of at least the categories of benefits identified in
subdivision (a) of this section.
(2) Coverage in each benefit category. A plan
not providing any coverage in one or more of the categories described in
paragraph (1) of this subdivision may be selected as the New York Benchmark
Plan if the plan is supplemented as follows:
(i) General supplementation methodology. A
plan that does not include items or services within one or more of the
categories described in subdivision (a) of this section shall be supplemented
by the addition of the entire category of such benefits offered under any other
benchmark plan option described in subdivision (c) of this section unless
otherwise described in this subdivision.
(ii) Supplementing pediatric oral services. A
plan lacking the category of pediatric oral services shall be supplemented by
the addition of the entire category of pediatric oral benefits from one of the
following:
(a) The Federal Employees
Dental/Vision Program ("FEDVIP") dental plan with the largest national
enrollment that is described in and offered to federal employees under
5 U.S.C. section
8952; or
(b) The benefits available under that State's
separate Children's Health Insurance Program ("CHIP") plan, if a separate CHIP
plan exists, to the eligibility group with the highest enrollment.
(iii) Supplementing pediatric
vision services. A plan lacking the category of pediatric vision services shall
be supplemented by the addition of the entire category of pediatric vision
benefits from one of the following:
(a) The
FEDVIP vision plan with the largest national enrollment that is offered to
federal employees under
5 U.S.C. section
8982; or
(b) The benefits available under the State's
separate CHIP plan, if a separate CHIP plan exists, to the eligibility group
with the highest enrollment.
(e) The superintendent may issue model
contract language identifying the coverage requirements for all individual and
small group accident and health insurance policies that provide hospital,
surgical, or medical expense coverage and all student accident and health
insurance policies delivered or issued for delivery in this State.
(f) The model language issued by the
superintendent summarizes the federal and state laws and rules that are
applicable to health insurance policies delivered or issued for delivery in
this State, including the requirement that the policies include coverage for
essential health benefits required by the federal Patient Protection and
Affordable Care Act. Every individual and small group accident and health
insurance policy that provides hospital, surgical, or medical expense coverage
and every student accident and health insurance policy delivered or issued for
delivery in this State shall comply with the federal and state laws and rules
that are applicable to health insurance policies issued in New York State as
set forth in the model language.
(g) Except for subdivisions (e) and (f) of
this section, the provisions of this section shall not be applicable unless and
until the essential health benefits provision in
42 U.S.C. section
18022 and 45 C.F.R. 15 6.100 et seq. are no
longer in effect or are modified as determined by the superintendent.
