§431:10A-116  Coverage for specificservices.  Every person insured under a policy of accident and health orsickness insurance delivered or issued for delivery in this State shall beentitled to the reimbursements and coverages specified below:

(1)  Notwithstanding any provision to the contrary,whenever a policy, contract, plan, or agreement provides for reimbursement forany visual or optometric service, which is within the lawful scope of practiceof a duly licensed optometrist, the person entitled to benefits or the personperforming the services shall be entitled to reimbursement whether the serviceis performed by a licensed physician or by a licensed optometrist.  Visual oroptometric services shall include eye or visual examination, or both, or a correctionof any visual or muscular anomaly, and the supplying of ophthalmic materials,lenses, contact lenses, spectacles, eyeglasses, and appurtenances thereto;

(2)  Notwithstanding any provision to the contrary,for all policies, contracts, plans, or agreements issued on or after May 30,1974, whenever provision is made for reimbursement or indemnity for any servicerelated to surgical or emergency procedures, which is within the lawful scopeof practice of any practitioner licensed to practice medicine in this State,reimbursement or indemnification under such policy, contract, plan, oragreement shall not be denied when such services are performed by a dentistacting within the lawful scope of the dentist's license;

(3)  Notwithstanding any provision to the contrary,whenever the policy provides reimbursement or payment for any service, which iswithin the lawful scope of practice of a psychologist licensed in this State,the person entitled to benefits or performing the service shall be entitled toreimbursement or payment, whether the service is performed by a licensedphysician or licensed psychologist;

(4)  Notwithstanding any provision to the contrary,each policy, contract, plan, or agreement issued on or after February 1, 1991,except for policies that only provide coverage for specified diseases or otherlimited benefit coverage, but including policies issued by companies subject tochapter 431, article 10A, part II and chapter 432, article 1 shall providecoverage for screening by low-dose mammography for occult breast cancer asfollows:

(A)  For women forty years of age and older, anannual mammogram; and

(B)  For a woman of any age with a history ofbreast cancer or whose mother or sister has had a history of breast cancer, amammogram upon the recommendation of the woman's physician.

The services provided in this paragraph aresubject to any coinsurance provisions that may be in force in these policies,contracts, plans, or agreements.

For the purpose of this paragraph, the term"low-dose mammography" means the x-ray examination of the breastusing equipment dedicated specifically for mammography, including but notlimited to the x-ray tube, filter, compression device, screens, films, andcassettes, with an average radiation exposure delivery of less than one radmid-breast, with two views for each breast.  An insurer may provide theservices required by this paragraph through contracts with providers; providedthat the contract is determined to be a cost-effective means of delivering theservices without sacrifice of quality and meets the approval of the director ofhealth;

(5)  (A)  (i)  Notwithstanding any provision to thecontrary, whenever a policy, contract, plan, or agreement provides coverage forthe children of the insured, that coverage shall also extend to the date ofbirth of any newborn child to be adopted by the insured; provided that theinsured gives written notice to the insurer of the insured's intent to adoptthe child prior to the child's date of birth or within thirty days after thechild's birth or within the time period required for enrollment of a naturalborn child under the policy, contract, plan, or agreement of the insured,whichever period is longer; provided further that if the adoption proceedingsare not successful, the insured shall reimburse the insurer for any expensespaid for the child; and

(ii)  Where notification has not been received bythe insurer prior to the child's birth or within the specified period followingthe child's birth, insurance coverage shall be effective from the first dayfollowing the insurer's receipt of legal notification of the insured's abilityto consent for treatment of the infant for whom coverage is sought; and

(B)  When the insured is a member of a healthmaintenance organization (HMO), coverage of an adopted newborn is effective:

(i)  From the date of birth of the adoptednewborn when the newborn is treated from birth pursuant to a provider contractwith the health maintenance organization, and written notice of enrollment inaccord with the health maintenance organization's usual enrollment process isprovided within thirty days of the date the insured notifies the healthmaintenance organization of the insured's intent to adopt the infant for whomcoverage is sought; or

(ii)  From the first day following receipt by thehealth maintenance organization of written notice of the insured's ability toconsent for treatment of the infant for whom coverage is sought and enrollmentof the adopted newborn in accord with the health maintenance organization'susual enrollment process if the newborn has been treated from birth by aprovider not contracting or affiliated with the health maintenanceorganization; and

(6)  Notwithstanding any provision to the contrary,any policy, contract, plan, or agreement issued or renewed in this State shallprovide reimbursement for services provided by advanced practice registerednurses recognized pursuant to chapter 457.  Services rendered by advancedpractice registered nurses are subject to the same policy limitations generallyapplicable to health care providers within the policy, contract, plan, oragreement. [L 1987, c 347, pt of §2; am L 1990, c 112, §2; am L 1991, c 268,§§1, 5; am L 1994, c 279, §3; am L 1995, c 47, §1; am L 1999, c 13, §2 and c222, §3; am L 2002, c 155, §55]

 

Note

 

  Director of health to monitor mammogram screening services toassure that the demand for screening does not exceed the ability of the medicalcommunity to safely provide the services.  L 1990, c 112, §5.

 

Cross References

 

  Sunset evaluations modified, see §§26H-4, 5.

  Civil relief for state military forces, see chapter 657D.

  Federally funded programs, see §431:10A-602.

  Newborn adopted children, see §432:1-602.6.

  Risk-based capital for insurers, see §§431:3-401 to 414.