4303 - Benefits.
§ 4303. Benefits. (a) Every contract issued by a hospital service corporation or health service corporation which provides coverage for in-patient hospital care shall also provide coverage: (1) For preadmission testing performed in hospital facilities prior to scheduled surgery. A patient who uses the out-patient facilities of a hospital shall be entitled to benefits for tests ordered by a physician which are performed as a planned preliminary to admission of the patient as an in-patient for surgery in the same hospital, provided that: (A) tests are necessary for and consistent with the diagnosis and treatment of the condition for which surgery is to be performed, (B) reservations for a hospital bed and for an operating room shall have been made prior to the performance of the tests, (C) surgery actually takes place within seven days of such presurgical tests, and (D) the patient is physically present at the hospital for the tests. (2) For services to treat an emergency condition in hospital facilities. For the purpose of this provision, "emergency condition" means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (A) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy, or (B) serious impairment to such person's bodily functions; (C) serious dysfunction of any bodily organ or part of such person; or (D) serious disfigurement of such person. (3) For home care to residents in this state. Such home care coverage shall be included at the inception of all new contracts and, with respect to all other contracts, added at any anniversary date of the contract subject to evidence of insurability. Such coverage may be subject to an annual deductible of not more than fifty dollars for each covered person and may be subject to a coinsurance provision which provides for coverage of not less than seventy-five percent of the reasonable cost of services for which payment may be made. No such corporation need provide such coverage to persons eligible for medicare. (A) Home care shall mean the care and treatment of a covered person who is under the care of a physician but only if: (i) hospitalization or confinement in a nursing facility as defined in subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq, would otherwise have been required if home care was not provided, and (ii) the plan covering the home health service is established and approved in writing by such physician. (B) Home care shall be provided by an agency possessing a valid certificate of approval or license issued pursuant to article thirty-six of the public health law. (C) Home care shall consist of one or more of the following: (i) part-time or intermittent home nursing care by or under the supervision of a registered professional nurse (R.N.), (ii) part-time or intermittent home health aide services which consist primarily of caring for the patient, (iii) physical, occupational or speech therapy if provided by the home health service or agency, and (iv) medical supplies, drugs and medications prescribed by a physician, and laboratory services by or on behalf of a certified home health agency or licensed home care services agency to the extent such items would have been covered or provided under the contract if the covered person had been hospitalized or confined in a skilled nursingfacility as defined in subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (D) For the purpose of determining the benefits for home care available to a covered person, each visit by a member of a home care team shall be considered as one home care visit. The contract may contain a limitation on the number of home care visits, but not less than forty such visits in any calendar year or in any continuous period of twelve months, for each covered person. Four hours of home health aide service shall be considered as one home care visit. Every contract issued by a hospital service corporation or health service corporation which provides coverage supplementing part A and part B of subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq, must make available and, if requested by a subscriber holding a direct payment contract or by all subscribers in a group remittance group or by the contract holder in the case of group contracts issued pursuant to section four thousand three hundred five of this article, provide coverage of supplemental home care visits beyond those provided by part A and part B, sufficient to produce an aggregate coverage of three hundred sixty-five home care visits per contract year. Such coverage shall be provided pursuant to regulations prescribed by the superintendent. Written notice of the availability of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state. The provisions of this subsection shall not apply to a contract issued pursuant to section four thousand three hundred five of this article which covers persons employed in more than one state or the benefit structure of which was the subject of collective bargaining affecting persons who are employed in more than one state. (b) Every contract issued by a medical expense indemnity corporation or a health service corporation which provides coverage for in-patient surgical care shall include coverage for a second surgical opinion by a qualified physician on the need for surgery, except that this provision shall not apply to a contract issued pursuant to section four thousand three hundred five of this article which covers persons employed in more than one state or the benefit structure of which was the subject of collective bargaining affecting persons who are employed in more than one state. (c) (1) * (A) Every contract issued by a corporation subject to the provisions of this article which provides hospital service, medical expense indemnity or both shall provide coverage for maternity care including hospital, surgical or medical care to the same extent that hospital service, medical expense indemnity or both are provided for illness or disease under the contract. Such maternity care coverage, other than coverage for perinatal complications, shall include inpatient hospital coverage for mother and for newborn for at least forty-eight hours after childbirth for any delivery other than a caesarean section, and for at least ninety-six hours following a caesarean section. Such coverage for maternity care shall include the services of a midwife licensed pursuant to article one hundred forty of the education law, practicing consistent with a written agreement pursuant to section sixty-nine hundred fifty-one of the education law and affiliated or practicing in conjunction with a facility licensed pursuant to article twenty-eight of the public health law, but no insurer shall be requiredto pay for duplicative routine services actually provided by both a licensed midwife and a physician. * NB Effective until October 28, 2010 * (A) Every contract issued by a corporation subject to the provisions of this article which provides hospital service, medical expense indemnity or both shall provide coverage for maternity care including hospital, surgical or medical care to the same extent that hospital service, medical expense indemnity or both are provided for illness or disease under the contract. Such maternity care coverage, other than coverage for perinatal complications, shall include inpatient hospital coverage for mother and for newborn for at least forty-eight hours after childbirth for any delivery other than a caesarean section, and for at least ninety-six hours following a caesarean section. Such coverage for maternity care shall include the services of a midwife licensed pursuant to article one hundred forty of the education law, practicing consistent with section sixty-nine hundred fifty-one of the education law and affiliated or practicing in conjunction with a facility licensed pursuant to article twenty-eight of the public health law, but no insurer shall be required to pay for duplicative routine services actually provided by both a licensed midwife and a physician. * NB Effective October 28, 2010 (B) Maternity care coverage also shall include, at minimum, parent education, assistance and training in breast or bottle feeding, and the performance of any necessary maternal and newborn clinical assessments. (C) The mother shall have the option to be discharged earlier than the time periods established in subparagraph (A) of this paragraph. In such case, the inpatient hospital coverage must include at least one home care visit, which shall be in addition to, rather than in lieu of, any home health care coverage available under the contract. The contract must cover the home care visit which may be requested at any time within forty-eight hours of the time of delivery (ninety-six hours in the case of caesarean section), and shall be delivered within twenty-four hours, (i) after discharge, or (ii) of the time of the mother's request, whichever is later. Such home care coverage shall be pursuant to the contract and subject to the provisions of this paragraph, and not subject to deductibles, coinsurance or copayments. (2) Coverage provided under this subsection for care and treatment during pregnancy shall include provision for not less than two payments, at reasonable intervals and for services rendered, for prenatal care and a separate payment for the delivery and postnatal care provided. (d) (1) A hospital service corporation or a health service corporation which provides coverage for in-patient hospital care must make available and, if requested by a person holding a direct payment individual contract or by all persons holding individual contracts in a group whose premiums are paid by a remitting agent or by the contract holder in the case of a group contract issued pursuant to section four thousand three hundred five of this article, provide coverage for care in nursing homes. Such coverage shall be made available at the inception of all new contracts and, with respect to all other contracts, at any anniversary date subject to evidence of insurability. Written notice of the availability of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state. (2) For the purpose of this subsection, care in nursing homes shall mean the continued care and treatment of a covered person who is underthe care of a physician but only if (i) the care is provided in a nursing home as defined in section two thousand eight hundred one of the public health law or a skilled nursing facility as defined in subchapter XVIII of the federal Social Security Act, 42 U.S.C. § 1395 et seq, (ii) the covered person has been in a hospital for at least three days immediately preceding admittance to the nursing home or the skilled nursing facility, and (iii) further hospitalization would otherwise be necessary. The aggregate of the number of covered days of care in a hospital and the number of covered days of care in a nursing home, with two days of care in a nursing home equivalent to one day of care in a hospital, need not exceed the number of covered days of hospital care provided under the contract in a benefit period. The level of benefits to be provided for nursing home care must be reasonably related to the benefits provided for hospital care. (e) (1) A hospital service corporation or a health service corporation which provides coverage for in-patient hospital care must make available and, if requested by a person holding a direct payment individual contract or by all persons holding individual contracts in a group whose premiums are paid by a remitting agent or by the contract holder in the case of a group contract issued pursuant to section four thousand three hundred five of this article, provide coverage for ambulatory care in hospital out-patient facilities, as a hospital is defined in section two thousand eight hundred one of the public health law, or subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. Written notice of the availability of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state. (2) For the purpose of this subsection, ambulatory care in hospital out-patient facilities shall mean services for diagnostic x-rays, laboratory and pathological examinations, physical and occupational therapy and radiation therapy, and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy, provided that such services and medications are (i) related to and necessary for the treatment or diagnosis of the patient's illness or injury, (ii) ordered by a physician and (iii) in the case of physical therapy, services are to be furnished in connection with the same illness for which the patient had been hospitalized or in connection with surgical care, but in no event need benefits for physical therapy be provided which commences more than six months after discharge from a hospital or the date surgical care was rendered, and in no event need benefits for physical therapy be provided after three hundred sixty-five days from the date of discharge from a hospital or the date surgical care was rendered. Such coverage shall be made available at the inception of all new contracts and, with respect to all other contracts, at any anniversary date subject to evidence of insurability. (f) (1) A medical expense indemnity corporation or a health service corporation which provides coverage for physicians' services must make available and, if requested by a person holding an individual direct payment contract or by all persons holding individual contracts in a group whose premiums are paid by a remitting agent or by the contract holder in the case of a group contract issued pursuant to section four thousand three hundred five of this article, provide coverage for ambulatory care in physicians' offices. Written notice of the availability of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract andannually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state. (2) For the purpose of this subsection, ambulatory care in physicians' offices shall mean services for diagnostic x-rays, radiation therapy, laboratory and pathological examinations, and services and medications used for nonexperimental cancer chemotherapy and cancer hormone therapy, provided that such services and medications are (i) related to and necessary for the treatment or diagnosis of the patient's illness or injury, and (ii) ordered by a physician. Such coverage shall be made available at the inception of all new contracts and, with respect to all other contracts at any anniversary date subject to evidence of insurability. (g) (1) A hospital service corporation or a health service corporation, which provides group, group remittance or school blanket coverage for inpatient hospital care, shall provide as part of its contract broad-based coverage for the diagnosis and treatment of mental, nervous or emotional disorders or ailments, however defined in such contract, at least equal to the coverage provided for other health conditions and shall include: (A) benefits for in-patient care in a hospital as defined by subdivision ten of section 1.03 of the mental hygiene law, which benefits may be limited to not less than thirty days of active treatment in any contract year, plan year or calendar year. (B) benefits for out-patient care provided in a facility issued an operating certificate by the commissioner of mental health pursuant to the provisions of article thirty-one of the mental hygiene law or in a facility operated by the office of mental health, which benefits may be limited to not less than twenty visits in any contract year, plan year or calendar year. Benefits for partial hospitalization program services shall be provided as an offset to covered inpatient days at a ratio of two partial hospitalization visits to one inpatient day of treatment. (C) Such coverage may be provided on a contract year, plan year or calendar year basis and shall be consistent with the provision of other benefits under the contract. Such coverage may be subject to annual deductibles, co-pays and coinsurance as may be deemed appropriate by the superintendent and shall be consistent with those imposed on other benefits under the contract. (D) For the purpose of this subsection, "active treatment" means treatment furnished in conjunction with in-patient confinement for mental, nervous or emotional disorders or ailments that meet such standards as shall be prescribed pursuant to the regulations of the commissioner of mental health. (E) In the event the group remittance group or contract holder is provided coverage under this subsection and under paragraph one of subsection (h) of this section from the same health service corporation, or under a contract that is jointly underwritten by two health service corporations or by a health service corporation and a medical expense indemnity corporation, the aggregate of the benefits for outpatient care obtained under subparagraph (B) of this paragraph and paragraph one of subsection (h) of this section may be limited to not less than twenty visits in any contract year, plan year or calendar year. (2) (A) A hospital service corporation or a health service corporation, which provides group, group remittance or school blanket coverage for inpatient hospital care, shall provide comparable coverage for adults and children with biologically based mental illness. Such hospital service corporation or health service corporation shall alsoprovide such comparable coverage for children with serious emotional disturbances. Such coverage shall be provided under the terms and conditions otherwise applicable under the contract, including network limitations or variations, exclusions, co-pays, coinsurance, deductibles or other specific cost sharing mechanisms. Provided further, where a contract provides both in-network and out-of-network benefits, the out-of-network benefits may have different coinsurance, co-pays, or deductibles, than the in-network benefits, regardless of whether the contract is written under one license or two licenses. (B) For purposes of this subsection, the term "biologically based mental illness" means a mental, nervous, or emotional condition that is caused by a biological disorder of the brain and results in a clinically significant, psychological syndrome or pattern that substantially limits the functioning of the person with the illness. Such biologically based mental illnesses are defined as schizophrenia/psychotic disorders, major depression, bipolar disorder, delusional disorders, panic disorder, obsessive compulsive disorders, anorexia, and bulimia. (3) For purposes of this subsection, the term "children with serious emotional disturbances" means persons under the age of eighteen years who have diagnoses of attention deficit disorders, disruptive behavior disorders, or pervasive development disorders, and where there are one or more of the following: (A) serious suicidal symptoms or other life-threatening self-destructive behaviors; (B) significant psychotic symptoms (hallucinations, delusion, bizarre behaviors); (C) behavior caused by emotional disturbances that placed the child at risk of causing personal injury or significant property damage; or (D) behavior caused by emotional disturbances that placed the child at substantial risk of removal from the household. (4) (A) The provisions of paragraph two of this subsection shall not apply to any group remittance group or group contract holder with fifty or fewer employees who is a group remittance group or group contract holder of a policy that is subject to the provisions of this section; provided however that a hospital service corporation or health service corporation must make available, and if requested by such group remitting agent or group contract holder, provide the coverage as specified in paragraph two of this subsection. Written notice of the availability of such coverage shall be delivered to the remitting agent or group contract holder prior to inception of such contract and annually thereafter. (B) The superintendent shall develop and implement a methodology to cover the cost to any such group contract holder for providing the coverage required in paragraph one of this subsection. Such methodology shall be financed from moneys appropriated from the General Fund that shall be made available to the superintendent for such purposes, to the extent of funds available. (5)(A) Nothing in this subsection shall be construed to prevent the medical management or utilization review of mental health benefits, including the use of prospective, concurrent or retrospective utilization review, preauthorization, and appropriateness criteria as to the level and intensity of treatment applicable to behavioral health. (B) Nothing in this subsection shall be construed to prevent a contract from providing services through a network of participating providers who shall meet certain requirements for participation, including provider credentialing. (C) Nothing in this subsection shall be construed to require a contract: (I) to cover mental health benefits or services forindividuals who are presently incarcerated, confined or committed to a local correctional facility or a prison, or a custodial facility for youth operated by the office of children and family services; or (II) to cover services solely because such services are ordered by a court. (D) Nothing in this subsection shall be deemed to require a contract to cover benefits or services deemed cosmetic in nature on the grounds that changing or improving an individual's appearance is justified by the individual's mental health needs. (h) (1) A medical expense indemnity corporation or a health service corporation, which provides group, group remittance or school blanket coverage for physician services, shall provide as part of its contract broad-based coverage for the diagnosis and treatment of mental, nervous or emotional disorders or ailments, however defined in such contract, at least equal to the coverage provided for other health conditions and shall include: benefits for outpatient care provided by a psychiatrist or psychologist licensed to practice in this state, a licensed clinical social worker who meets the requirements of subsection (n) of this section, or a professional corporation or university faculty practice corporation thereof, which benefits may be limited to not less than twenty visits in any contract year, plan year or calendar year. Such coverage may be provided on a contract year, plan year or calendar year basis and shall be consistent with the provision of other benefits under the contract. Such coverage may be subject to annual deductibles, co-pays and coinsurance as may be deemed appropriate by the superintendent and shall be consistent with those imposed on other benefits under the contract. In the event the group remittance group or contract holder is provided coverage provided under this paragraph and under subparagraph (B) of paragraph one of subsection (g) of this section from the same health service corporation, or under a contract which is jointly underwritten by two health service corporations or by a health service corporation and a medical expense indemnity corporation, the aggregate of the benefits for out-patient care obtained under subparagraph (B) of paragraph one of subsection (g) of this section and this paragraph may be limited to not less than twenty visits in any contract year, plan year or calendar year. (2) (A) A medical expense indemnity corporation or a health service corporation, which provides group, group remittance or school blanket coverage for physician services, shall provide comparable coverage for adults and children with biologically based mental illness. Such medical expense indemnity corporation or health service corporation shall also provide such comparable coverage for children with serious emotional disturbances. Such coverage shall be provided under the terms and conditions otherwise applicable under the contract, including network limitations or variations, exclusions, co-pays, coinsurance, deductibles or other specific cost sharing mechanisms. Provided further, where a contract provides both in-network and out-of-network benefits, the out-of-network benefits may have different coinsurance, co-pays, or deductibles, than the in-network benefits, regardless of whether the contract is written under one license or two licenses. (B) For purposes of this subsection, the term "biologically based mental illness" means a mental, nervous, or emotional condition that is caused by a biological disorder of the brain and results in a clinically significant, psychological syndrome or pattern that substantially limits the functioning of the person with the illness. Such biologically based mental illnesses are defined as schizophrenia/psychotic disorders, major depression, bipolar disorder, delusional disorders, panic disorder, obsessive compulsive disorder, anorexia, and bulimia.(3) For purposes of this subsection, the term "children with serious emotional disturbances" means persons under the age of eighteen years who have diagnoses of attention deficit disorders, disruptive behavior disorders, or pervasive development disorders, and where there are one or more of the following: (A) serious suicidal symptoms or other life-threatening self-destructive behaviors; (B) significant psychotic symptoms (hallucinations, delusion, bizarre behaviors); (C) behavior caused by emotional disturbances that placed the child at risk of causing personal injury or significant property damage; or (D) behavior caused by emotional disturbances that placed the child at substantial risk of removal from the household. (4) (A) The provisions of paragraph two of this subsection shall not apply to any group remittance group or group contract holder with fifty or fewer employees who is a group remittance group or group contract holder of a contract that is subject to the provisions of this section; provided, however, that a hospital service corporation or health service corporation must make available, and if requested by such group remitting agent or group contract holder, provide the coverage as specified in paragraph two of this subsection. Written notice of the availability of the coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter. (B) The superintendent shall develop and implement a methodology to cover the cost to any such group remittance group and group contract holder for providing the coverage required in paragraph one of this subsection. Such methodology shall be financed from moneys appropriated from the General Fund that shall be made available to the superintendent for such purposes, to the extent of funds available. (5)(A) Nothing in this subsection shall be construed to prevent the medical management or utilization review of mental health benefits, including the use of prospective, concurrent or retrospective utilization review, preauthorization, and appropriateness criteria as to the level and intensity of treatment applicable to behavioral health. (B) Nothing in this subsection shall be construed to prevent a contract from providing services through a network of participating providers who shall meet certain requirements for participation, including provider credentialing. (C) Nothing in this subsection shall be construed to require a contract: (I) to cover mental health benefits or services for individuals who are presently incarcerated, confined or committed to a local correctional facility or a prison, or a custodial facility for youth operated by the office of children and family services; or (II) to cover services solely because such services are ordered by a court. (D) Nothing in this subsection shall be deemed to require a contract to cover benefits or services deemed cosmetic in nature on the grounds that changing or improving an individual's appearance is justified by the individual's mental health needs. (i) A medical expense indemnity corporation or health service corporation which provides coverage for physicians, psychiatrists or psychologists for psychiatric or psychological services or for the diagnosis and treatment of mental, nervous or emotional disorders and ailments, however defined in such contract, must make available and if requested by all persons holding individual contracts in a group whose premiums are paid by a remitting agent or by the contract holder in the case of a group contract issued pursuant to section four thousand three hundred five of this article, provide the same coverage for suchservices when performed by a licensed clinical social worker, within the lawful scope of his or her practice, who is licensed pursuant to article one hundred fifty-four of the education law. The state board for social work shall maintain a list of all licensed clinical social workers qualified for reimbursement under this subsection. Such coverage shall be made available at the inception of all new contracts and, with respect to all other contracts, at any anniversary date subject to evidence of insurability. Written notice of the availability of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state. (j)(1) A health service corporation or medical expense indemnity corporation which provides medical, major-medical or similar comprehensive-type coverage must provide coverage for the provision of preventive and primary care services. (2) For purposes of this subsection, preventive and primary care services shall mean the following services rendered to a dependent child of a subscriber from the date of birth through the attainment of nineteen years of age: (i) an initial hospital check-up and well-child visits scheduled in accordance with the prevailing clinical standards of a national association of pediatric physicians designated by the commissioner of health (except for any standard that would limit the specialty or forum of licensure of the practitioner providing the service other than the limits under state law). Coverage for such services rendered shall be provided only to the extent that such services are provided by or under the supervision of a physician, or other professional licensed under article one hundred thirty-nine of the education law whose scope of practice pursuant to such law includes the authority to provide the specified services. Coverage shall be provided for such services rendered in a hospital, as defined in section twenty-eight hundred one of the public health law, or in an office of a physician or other professional licensed under article one hundred thirty-nine of the education law whose scope of practice pursuant to such law includes the authority to provide the specified services, (ii) at each visit, services in accordance with the prevailing clinical standards of such designated association, including a medical history, a complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations and laboratory tests which tests are ordered at the time of the visit and performed in the practitioner's office, as authorized by law, or in a clinical laboratory, and (iii) necessary immunizations as determined by the superintendent in consultation with the commissioner of health consisting of at least adequate dosages of vaccine against diphtheria, pertussis, tetanus, polio, measles, rubella, mumps, haemophilus influenzae type b and hepatitis b which meet the standards approved by the United States public health service for such biological products. Such coverage shall not be subject to annual deductibles and/or coinsurance. Such coverage shall not restrict or eliminate existing coverage provided by the contract. (k) A hospital service corporation or a health service corporation which provides group, group remittance or school blanket coverage for inpatient hospital care must make available and if requested by the contract holder provide coverage for the diagnosis and treatment of chemical abuse and chemical dependence, however defined in such policy, provided, however, that the term chemical abuse shall mean and includealcohol and substance abuse and chemical dependence shall mean and include alcoholism and substance dependence, however defined in such policy, except that this provision shall not apply to a policy which covers persons employed in more than one state or the benefit structure of which was the subject of collective bargaining affecting persons who are employed in more than one state. Such coverage shall be at least equal to the following: (1) with respect to benefits for detoxification as a consequence of chemical dependence, inpatient benefits for care in a hospital or detoxification facility may not be limited to less than seven days of active treatment in any calendar year; and (2) with respect to benefits for inpatient rehabilitation services, such benefits may not be limited to less than thirty days of inpatient rehabilitation in a hospital based or free standing chemical dependence facility in any calendar year. Such coverage may be limited to facilities in New York state which are certified by the office of alcoholism and substance abuse services and, in other states, to those which are accredited by the joint commission on accreditation of hospitals as alcoholism, substance abuse, or chemical dependence treatment programs. Such coverage shall be made available at the inception of all new policies and with respect to policies issued before the effective date of this subsection at the first annual anniversary date thereafter, without evidence of insurability and at any subsequent annual anniversary date subject to evidence of insurability. Such coverage may be subject to annual deductibles and co-insurance as may be deemed appropriate by the superintendent and are consistent with those imposed on other benefits within a given policy. Further, each hospital service corporation or health service corporation shall report to the superintendent each year the number of contract holders to whom it has issued policies for the inpatient treatment of chemical dependence, and the approximate number of persons covered by such policies. Such coverage shall not replace, restrict or eliminate existing coverage provided by the policy. Written notice of the availability of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state. (l) A hospital service corporation or a health service corporation which provides group, group remittance or school blanket coverage for inpatient hospital care must provide coverage for at least sixty outpatient visits in any calendar year for the diagnosis and treatment of chemical dependence of which up to twenty may be for family members, except that this provision shall not apply to a contract issued pursuant to section four thousand three hundred five of this article which covers persons employed in more than one state or the benefit structure of which was the subject of collective bargaining affecting persons who are employed in more than one state. Such coverage may be limited to facilities in New York state certified by the office of alcoholism and substance abuse services or licensed by such office as outpatient clinics or medically supervised ambulatory substance abuse programs and, in other states, to those which are accredited by the joint commission on accreditation of hospitals as alcoholism or chemical dependence substance abuse treatment programs. Such coverage may be subject to annual deductibles and co-insurance as may be deemed appropriate by the superintendent and are consistent with those imposed on other benefits within a given policy. Such coverage shall not replace, restrict or eliminate existing coverage provided by the policy. Except as otherwise provided in the applicable policy or contract, no hospital servicecorporation or health service corporation providing coverage for alcoholism or substance abuse services pursuant to this section shall deny coverage to a family member who identifies themself as a family member of a person suffering from the disease of alcoholism, substance abuse or chemical dependency and who seeks treatment as a family member who is otherwise covered by the applicable policy or contract pursuant to this section. The coverage required by this subsection shall include treatment as a family member pursuant to such family members' own policy or contract provided such family member (i) does not exceed the allowable number of family visits provided by the applicable policy or contract pursuant to this section, and (ii) is otherwise entitled to coverage pursuant to this section and such family members' applicable policy or contract. (m) A medical expense indemnity corporation or a health service corporation which provides coverage for any service within the lawful scope of practice of a duly licensed registered professional nurse must make available, and if requested by all subscribers in a group remittance group, or by a contract holder in the case of a group contract issued pursuant to section four thousand three hundred five of this chapter, provide reimbursement for such services when performed by a duly licensed registered professional nurse provided, however, that reimbursement shall not be made for nursing services provided to a subscriber in a general hospital, nursing home, or a facility providing health related services, as such terms are defined in section twenty-eight hundred one of the public health law, or in a facility, as such term is defined in subdivision six of section 1.03 of the mental hygiene law, or in a physician's office. Such coverage may be subject to annual deductibles and co-insurance as may be deemed appropriate by the superintendent and are consistent with those imposed on other benefits within a given policy. Such coverage shall not replace, restrict or eliminate existing coverage provided by the policy. Coverage for the services of a duly licensed registered professional nurse need be provided only if the nature of the patient's illness or condition requires nursing care which can appropriately be provided by a person with the education and professional skill of a registered professional nurse and the nursing care is necessary in the treatment of the patient's illness or condition. Written notice of the availability of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state. (n) In addition to the requirements of subsection (i) of this section, every health service or medical expense indemnity corporation issuing a group contract pursuant to this section or a group remittance contract for delivery in this state which contract provides reimbursement to subscribers or physicians, psychiatrists or psychologists for psychiatric or psychological services or for the diagnosis and treatment of mental, nervous or emotional disorders and ailments, however defined in such contract, must provide the same coverage to persons covered under the group contract for such services when performed by a licensed clinical social worker, within the lawful scope of his or her practice, who is licensed pursuant to subdivision two of section seven thousand seven hundred four of the education law and in addition shall have either (i) three or more additional years experience in psychotherapy, which for the purposes of this subsection shall mean the use of verbal methods in interpersonal relationships with the intent of assisting aperson or persons to modify attitudes and behavior which are intellectually, socially or emotionally maladaptive, under supervision, satisfactory to the state board for social work, in a facility, licensed or incorporated by an appropriate governmental department, providing services for diagnosis or treatment of mental, nervous or emotional disorders or ailments, or (ii) three or more additional years experience in psychotherapy under the supervision, satisfactory to the state board for social work, of a psychiatrist, a licensed and registered psychologist or a licensed clinical social worker qualified for reimbursement pursuant to subsection (i) of this section, or (iii) a combination of the experience specified in paragraphs (i) and (ii) totaling three years, satisfactory to the state board for social work. The state board for social work shall maintain a list of all licensed clinical social workers qualified for reimbursement under this subsection. (o) A hospital service corporation or a health service corporation which provides coverage for inpatient hospital care must make available and, if requested by all persons holding individual contracts in a group whose premiums are paid by a remitting agent or by the contractholder in the case of a group contract issued pursuant to section four thousand three hundred five of this article, provide coverage for hospice care. For the purposes of this subsection, hospice care shall mean the care and treatment of a covered person who has been certified by such person's primary attending physician as having a life expectancy of six months or less and which is provided by a hospice organization certified pursuant to article forty of the public health law or under a similar certification process required by the state in which the hospice organization is located. Hospice care coverage shall be at least equal to: (1) a total of two hundred ten days of coverage beginning with the first day on which care is provided, for inpatient hospice care in a hospice or in a hospital and home care and outpatient services provided by the hospice, including drugs and medical supplies, and (2) five visits for bereavement counseling services, either before or after the insured's death, provided to the family of the terminally ill insured. Such coverage shall be made available at the inception of all new contracts and, with respect to contracts issued before the effective date of this provision, at the first annual anniversary date thereafter, without evidence of insurability and at any subsequent annual anniversary date subject to evidence of insurability. Such coverage may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and are consistent with those imposed on other benefits within a given contract period. Written notice of the availability of such coverage shall be delivered to the group remitting agent or group contract holder prior to inception of such contract and annually thereafter, except that this notice shall not be required where a policy covers two hundred or more employees or where the benefit structure was the subject of collective bargaining affecting persons who are employed in more than one state. (p) (1) A medical expense indemnity corporation, a hospital service corporation or a health service corporation which provides coverage for hospital, surgical or medical care shall provide the following coverage for mammography screening for occult breast cancer: (A) upon the recommendation of a physician, a mammogram at any age for covered persons having a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer; (B) a single baseline mammogram for covered persons aged thirty-five through thirty-nine, inclusive; and (C) an annual mammogram for covered persons aged forty and older.The coverage required in this paragraph may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. (2) In no event shall coverage pursuant to this section include more than one annual screening. (3) For purposes of this subsection, mammography screening means an X-ray examination of the breast using dedicated equipment, including X-ray tube, filter, compression device, screens, films and cassettes, with an average glandular radiation dose less than 0.5 rem per view per breast. * (q) (1) Every policy issued by a medical expense indemnity corporation, a hospital service corporation or a health service corporation which provides coverage for prescribed drugs approved by the food and drug administration of the United States government for the treatment of certain types of cancer shall not exclude coverage of any such drug on the basis that such drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the food and drug administration. Provided, however, that such drug must be recognized for treatment of the specific type of cancer for which the drug has been prescribed in one of the following established reference compendia: (i) the American Medical Association Drug Evaluations; (ii) the American Hospital Formulary Service Drug Information; or (iii) the United States Pharmacopeia Drug Information; or recommended by review article or editorial comment in a major peer reviewed professional journal. (2) Notwithstanding the provisions of this subsection, coverage shall not be required for any experimental or investigational drugs or any drug which the food and drug administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed. The provisions of this subsection shall apply to cancer drugs only and nothing herein shall be construed to create, impair, alter, limit, modify, enlarge, abrogate or prohibit reimbursement for drugs used in the treatment of any other disease or condition. * NB Effective until January 1, 2011 * (q) (1) Every policy issued by a medical expense indemnity corporation, a hospital service corporation or a health service corporation which provides coverage for prescribed drugs approved by the food and drug administration of the United States government for the treatment of certain types of cancer shall not exclude coverage of any such drug on the basis that such drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the food and drug administration. Provided, however, that such drug must be recognized for treatment of the specific type of cancer for which the drug has been prescribed in one of the following established reference compendia: (i) the American Hospital Formulary Service-Drug Information (AHFS-DI); (ii) National Comprehensive Cancer Networks Drugs and Biologics Compendium; (iii) Thomson Micromedex DrugDex; (iv) Elsevier Gold Standard's Clinical Pharmacology; or other authoritative compendia as identified by the Federal Secretary of Health and Human Services or the Centers for Medicare & Medicaid Services (CMS); or recommended by review article or editorial comment in a major peer reviewed professional journal.(2) Notwithstanding the provisions of this subsection, coverage shall not be required for any experimental or investigational drugs or any drug which the food and drug administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed. The provisions of this subsection shall apply to cancer drugs only and nothing herein shall be construed to create, impair, alter, limit, modify, enlarge, abrogate or prohibit reimbursement for drugs used in the treatment of any other disease or condition. * NB Effective January 1, 2011 (r) Consistent with federal law, a hospital service corporation or a health service corporation which provides coverage supplementing part A and part B of subchapter XVIII of the federal Social Security Act, 42 USC §§ 1395 et seq., shall make available and, if requested by a person holding a direct payment individual contract or by all persons holding individual contracts in a group whose premiums are paid by a remitting agent or by a contract holder in the case of a group contract issued pursuant to section four thousand three hundred five of this article, provide coverage for at least ninety days of care in a nursing home as defined in section twenty-eight hundred one of the public health law, except when such coverage would duplicate coverage that is available under the aforementioned subchapter XVIII. Such coverage shall be made available at the inception of all new contracts and, with respect to all other contracts at each anniversary date of the contract. (1) Coverage shall be subject to a copayment of twenty-five dollars per day. (2) Brochures describing such coverage must be provided at the time of application for all new contracts and thereafter on each anniversary date of the contract, and with respect to all other contracts annually at each anniversary date of the contract. Such brochures must be approved by the superintendent in consultation with the commissioner of health. Such insurers shall report to the superintendent each year the number of contract holders to whom such insurers have issued such policies for nursing home coverage and the approximate number of persons covered by such policies. (3) The commensurate rate for the coverage must be approved by the superintendent. * (s) (1) A hospital service corporation or health service corporation which provides coverage for hospital care shall not exclude coverage for hospital care for diagnosis and treatment of correctable medical conditions otherwise covered by the policy solely because the medical condition results in infertility; provided, however that: (A) subject to the provisions of paragraph three of this subsection, in no case shall such coverage exclude surgical or medical procedures provided as part of such hospital care which would correct malformation, disease or dysfunction resulting in infertility; and (B) provided, further however, that subject to the provisions of paragraph three of this subsection, in no case shall such coverage exclude diagnostic tests and procedures provided as part of such hospital care that are necessary to determine infertility or that are necessary in connection with any surgical or medical treatments or prescription drug coverage provided pursuant to this subsection, including such diagnostic tests and procedures as hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post coital tests, testis biopsy, semen analysis, blood tests and ultrasound; and(C) provided, further however, every such policy which provides coverage for prescription drugs shall include, within such coverage, coverage for prescription drugs approved by the federal Food and Drug Administration for use in the diagnosis and treatment of infertility in accordance with paragraph three of this subsection. (2) A medical expense indemnity or health service corporation which provides coverage for surgical and medical care shall not exclude coverage for surgical and medical care for diagnosis and treatment of correctable medical conditions otherwise covered by the policy solely because the medical condition results in infertility; provided, however that: (A) subject to the provisions of paragraph three of this subsection, in no case shall such coverage exclude surgical or medical procedures which would correct malformation, disease or dysfunction resulting in infertility; and (B) provided, further however, that subject to the provisions of paragraph three of this subsection, in no case shall such coverage exclude diagnostic tests and procedures that are necessary to determine infertility or that are necessary in connection with any surgical or medical treatments or prescription drug coverage provided pursuant to this subsection, including such diagnostic tests and procedures as hysterosalpingogram, hysteroscopy, endometrial biopsy, laparoscopy, sono-hysterogram, post coital tests, testis biopsy, semen analysis, blood tests and ultrasound; and (C) provided, further however, every such policy which provides coverage for prescription drugs shall include, within such coverage, coverage for prescription drugs approved by the federal Food and Drug Administration for use in the diagnosis and treatment of infertility in accordance with paragraph three of this subsection. (3) Coverage of diagnostic and treatment procedures, including prescription drugs used in the diagnosis and treatment of infertility as required by paragraphs one and two of this subsection shall be provided in accordance with this paragraph. (A) Coverage shall be provided for persons whose ages range from twenty-one through forty-four years, provided that nothing herein shall preclude the provision of coverage to persons whose age is below or above such range. (B) Diagnosis and treatment of infertility shall be prescribed as part of a physician's overall plan of care and consistent with the guidelines for coverage as referenced in this paragraph. (C) Coverage may be subject to co-payments, coinsurance and deductibles as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given policy. (D) Coverage shall be limited to those individuals who have been previously covered under the policy for a period of not less than twelve months, provided that for the purposes of this paragraph "period of not less than twelve months" shall be determined by calculating such time from either the date the insured was first covered under the existing policy or from the date the insured was first covered by a previously in-force converted policy, whichever is earlier. (E) Coverage shall not be required to include the diagnosis and treatment of infertility in connection with: (i) in vitro fertilization, gamete intrafallopian tube transfers or zygote intrafallopian tube transfers; (ii) the reversal of elective sterilizations; (iii) sex change procedures; (iv) cloning; or (v) medical or surgical services or procedures that are deemed to be experimental in accordance with clinical guidelines referenced in subparagraph (F) of this paragraph.(F) The superintendent, in consultation with the commissioner of health, shall promulgate regulations which shall stipulate the guidelines and standards which shall be used in carrying out the provisions of this paragraph, which shall include: (i) The determination of "infertility" in accordance with the standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine; (ii) The identification of experimental procedures and treatments not covered for the diagnosis and treatment of infertility determined in accordance with the standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine; (iii) The identification of the required training, experience and other standards for health care providers for the provision of procedures and treatments for the diagnosis and treatment of infertility determined in accordance with the standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine; and (iv) The determination of appropriate medical candidates by the treating physician in accordance with the standards and guidelines established and adopted by the American College of Obstetricians and Gynecologists and/or the American Society for Reproductive Medicine. * NB There are 2 sb (s)'s * (s) Notwithstanding any provision of a contract issued by a medical expense indemnity corporation, a dental expense indemnity corporation or health service corporation, every contract which provides coverage for care provided through licensed health professionals who can bill for services shall provide the same coverage and reimbursement for such service provided pursuant to a clinical practice plan established pursuant to subdivision fourteen of section two hundred six of the public health law. * NB There are 2 sb (s)'s (t) (1) A medical expense indemnity corporation, a hospital service corporation or a health service corporation which provides coverage for hospital, surgical, or medical care shall provide coverage for an annual cervical cytology screening for cervical cancer and its precursor states for women aged eighteen and older. Such coverage may be subject to annual deductibles and coinsurance as may be deemed appropriate by the superintendent and as are consistent with those established for other benefits within a given contract. (2) For purposes of this subsection, cervical cytology screening shall include an annual pelvic examination, collection and preparation of a Pap smear, and laboratory and diagnostic services provided in connection with examining and evaluating the Pap smear. (u) (1) A medical expense indemnity corporation or a health service corporation which provides medical coverage that includes coverage for physician services in a physician's office and every policy which provides major medical or similar comprehensive-type coverage shall include coverage for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or other licensed health care provider legally authorized to prescribe under title eight of the education law: blood glucose monitors and blood glucose monitors for the visually impaired, data management systems, test strips for glucose monitors and visual reading and urine testing strips, insulin, injection aids, cartridges for the visually impaired, syringes, insulin pumps and appurtenances thereto, insulin infusion devices, and oral agents for controlling blood sugar. In addition, thecommissioner of the department of health shall provide and periodically update by rule or regulation a list of additional diabetes equipment and related supplies such as are medically necessary for the treatment of diabetes, for which there shall also be coverage. Such policies shall also include coverage for diabetes self-management education to ensure that persons with diabetes are educated as to the proper self-management and treatment of their diabetic condition, including information on proper diets. Such coverage for self-management education and education relating to diet shall be limited to visits medically necessary upon the diagnosis of diabetes, where a physician diagnoses a significant change in the patient's symptoms or conditions which necessitate changes in a patient's self-management, or where reeducation or refresher education is necessary. Such education may be provided by the physician or other licensed health care provider legally authorized to prescribe under title eight of the education law, or their staff, as part of an office visit for diabetes diagnosis or treatment, or b