State Codes and Statutes

Statutes > New-york > Isc > Article-32 > 3221

§  3221.  Group  or  blanket  accident  and health insurance policies;  standard provisions. (a) No policy of  group  or  blanket  accident  and  health  insurance shall, except as provided in subsection (d) hereof, be  delivered or issued for delivery in this state  unless  it  contains  in  substance the following provisions or provisions which in the opinion of  the   superintendent   are   more  favorable  to  the  holders  of  such  certificates or not less favorable to the holders of  such  certificates  and   more  favorable  to  policyholders,  provided  however,  that  the  provisions set forth in paragraphs six and thirteen of  this  subsection  shall  not  be  applicable  to  any  such  policy  which  is issued to a  policyholder in accordance with subparagraph (E)  of  paragraph  one  of  subsection  (c) of section four thousand two hundred thirty-five of this  chapter:    (1) (A) No statement made  by  the  person  insured  shall  avoid  the  insurance  or  reduce  benefits thereunder unless contained in a written  instrument signed by the person insured.    (B) All statements contained in any such written instrument  shall  be  deemed representations and not warranties.    (2)  That  no agent has authority to change the policy or waive any of  its provisions and that no change in the policy shall  be  valid  unless  approved  by  an  officer of the insurer and evidenced by endorsement on  the policy, or by amendment to the policy signed by the policyholder and  the insurer.    (3) That all new employees or new members in the classes eligible  for  insurance must be added to such class for which they are eligible.    (4)  That  all  premiums due under the policy shall be remitted by the  employer or employers of the persons insured or by some other designated  person acting on behalf of the association  or  group  insured,  to  the  insurer  on or before the due date thereof, with such period of grace as  may be specified therein.    (5) The conditions under which the insurer may decline  to  renew  the  policy.    (6)  That  the insurer shall issue either to the employer or person in  whose name such policy is issued, for delivery to  each  member  of  the  insured  group,  a certificate setting forth in summary form a statement  of the essential features of the insurance coverage and in substance the  following provisions of this subsection.    (7) The ages,  to  which  the  insurance  provided  therein  shall  be  limited;  and  the ages, for which additional restrictions are placed on  benefits, and the additional restrictions placed on the benefits at such  ages.    (8) That written notice of claim must be given to the  insurer  within  twenty  days after the occurrence or commencement of any loss covered by  the policy. Failure to give notice within such time shall not invalidate  or reduce any claim if it shall be shown not  to  have  been  reasonably  possible  to  give  such notice and that notice was given as soon as was  reasonably possible.    * (9) That in the case of claim  for  loss  of  time  for  disability,  written  proof  of  such  loss  must  be furnished to the insurer within  thirty days after the commencement of the period for which  the  insurer  is liable, and that subsequent written proofs of the continuance of such  disability  must  be  furnished  to the insurer at such intervals as the  insurer may reasonably require, and that in the case of  claim  for  any  other  loss, written proof of such loss must be furnished to the insurer  within ninety days after the date of such loss. Failure to furnish  such  proof  within  such  time shall not invalidate or reduce any claim if it  shall be shown not to have been  reasonably  possible  to  furnish  suchproof  within  such  time,  provided such proof was furnished as soon as  reasonably possible.    * NB Effective until January 1, 2011    * (9)  That  in  the  case  of  claim for loss of time for disability,  written proof of such loss must  be  furnished  to  the  insurer  within  thirty  days  after the commencement of the period for which the insurer  is liable, and that subsequent written proofs of the continuance of such  disability must be furnished to the insurer at  such  intervals  as  the  insurer  may  reasonably  require, and that in the case of claim for any  other loss, written proof of such loss must be furnished to the  insurer  within  one  hundred twenty days after the date of such loss. Failure to  furnish such proof within such time shall not invalidate or  reduce  any  claim  if  it  shall  be  shown  not to have been reasonably possible to  furnish such proof within such time, provided such proof  was  furnished  as soon as reasonably possible.    * NB Effective January 1, 2011    (10)  That  the  insurer will furnish to the person making claim or to  the policyholder for delivery to such person such forms as  are  usually  furnished  by  it  for  filing  proof  of  loss.  If  such forms are not  furnished before the  expiration  of  fifteen  days  after  the  insurer  receives  notice  of  any claim under the policy, the person making such  claim shall be deemed to have complied  with  the  requirements  of  the  policy  as to proof of loss upon submitting within the time fixed in the  policy for filing proof of loss, written proof covering the  occurrence,  character and extent of the loss for which claim is made.    (11)  That the insurer shall have the right and opportunity to examine  the person of the individual for whom claim is made when and so often as  it may reasonably require during the pendency of claim under the  policy  and  also  the right and opportunity to make an autopsy in case of death  where it is not prohibited by law.    (12) That benefits payable under the policy other  than  benefits  for  loss  of  time will be payable not more than sixty days after receipt of  proof, and that, subject to due  proof  of  loss  all  accrued  benefits  payable  under  the  policy  for  loss  of  time  will  be paid not less  frequently than monthly during the continuance of the period  for  which  the  insurer  is  liable,  and  that any balance remaining unpaid at the  termination of such period will be paid immediately upon receipt of such  proof.    (13) That indemnity for loss of life of  the  insured  is  payable  in  accordance  with  subsection  (e)  of  section four thousand two hundred  thirty-five of this chapter; and  that  all  other  indemnities  of  the  policy  are  payable to the insured, except as may be otherwise provided  in accordance with  such  subsection;  and  that  if  a  beneficiary  is  designated,  the  consent  of  the beneficiary shall not be requisite to  change of beneficiary,  or  to  any  other  changes  in  the  policy  or  certificate, except as may be specifically provided by the policy.    (14) That no action at law or in equity shall be brought to recover on  the policy prior to the expiration of sixty days after proof of loss has  been filed in accordance with the requirements of the policy and that no  such action shall be brought after the expiration of two years following  the time such proof of loss is required by the policy.    (15)  Any policy and certificate, other than one issued in fulfillment  of the continuing care responsibilities of an operator of  a  continuing  care  retirement  community  in accordance with article forty-six of the  public health law, made available because of residence in  a  particular  facility,  housing development, or community shall contain the following  notice in twelve point type in bold face on the first page:"NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF  A CONTINUING CARE RETIREMENT CONTRACT.  AVAILABILITY  OF  THIS  COVERAGE  WILL  NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT  COMMUNITY."    * (16)  No policy delivered or issued for delivery in this state which  provides coverage for prescription drugs  and  for  which  cost-sharing,  deductibles  or  co-insurance  obligations are determined by category of  prescription   drugs   shall   impose   cost-sharing,   deductibles   or  co-insurance  obligations  for  any  prescription  drug that exceeds the  dollar amount of cost-sharing, deductibles or  co-insurance  obligations  for non-preferred brand drugs or its equivalent (or brand drugs if there  is no non-preferred brand drug category).    * NB Effective October 31, 2010    (b)  No  such policy shall be delivered or issued for delivery in this  state unless a schedule of the premium rates  pertaining  to  such  form  shall have been filed with the superintendent.    (c)  Any  portion of any such policy, which purports, by reason of the  circumstances under which a loss is incurred,  to  reduce  any  benefits  promised  thereunder  to  an amount less than that provided for the same  loss occurring under ordinary circumstances, shall be printed,  in  such  policy  and in each certificate issued thereunder, in bold face type and  with greater prominence than any other  portion  of  the  text  of  such  policy  or  certificate; and all other exceptions of the policy shall be  printed in the policy and in the certificate, with the  same  prominence  as  the  benefits  to  which they apply. If any such policy contains any  provision which affects the liability of the  insurer,  on  the  grounds  stated  in subparagraph (J) or (K) of paragraph two of subsection (d) of  section three thousand two hundred sixteen of this  article,  then  such  provision  shall  be contained in the policy and certificate in the form  set forth in such section.    (d) (1) The superintendent may approve any form of certificate  to  be  issued  under  a blanket accident and health insurance policy as defined  in section four thousand two hundred thirty-seven of this chapter, which  omits or modifies any of the provisions  hereinbefore  required,  if  he  deems  such  omission or modification suitable for the character of such  insurance and not unjust to the persons insured thereunder.    (2) The superintendent may approve any form of group insurance  policy  providing  disability  benefits to be issued pursuant to article nine of  the workers' compensation  law  which  omits  or  modifies  any  of  the  provisions  hereinbefore  required,  if such omission or modification is  not inconsistent with the provisions of such article nine and  he  deems  such  omission  or  modification  suitable  for  the  character  of such  insurance and not unjust to the persons insured thereunder.    (3) The superintendent may also approve any form  of  group  insurance  policy   to  be  issued  to  a  social  services  district  pursuant  to  subdivision two of section three hundred  sixty-seven-a  of  the  social  services law, which omits or modifies any of the provisions hereinbefore  required,  if  he  deems  such omission or modification suitable for the  character of such insurance.    (e)  (1)  A  group  policy  providing  hospital  or  surgical  expense  insurance  for  other  than  specific  diseases  or accident only, shall  provide that if the insurance on an employee or member insured under the  group policy ceases because of  termination  of  (I)  employment  or  of  membership  in  the  class  or  classes  eligible for coverage under the  policy or (II)  the  policy,  for  any  reason  whatsoever,  unless  the  policyholder  has  replaced the group policy with similar and continuous  coverage for the  same  group  whether  insured  or  self-insured,  such  employee  or  member  who has been insured under the group policy for atleast three months shall be entitled  to  have  issued  to  him  by  the  insurer  without  evidence  of insurability upon application made to the  insurer within forty-five days after such termination,  and  payment  of  the  quarterly,  or,  at  the  option  of the employee or member, a less  frequent premium applicable to the class of risk  to  which  the  person  belongs,  the  age of such person, and the form and amount of insurance,  an individual policy of insurance. The insurer may, at its option  elect  to  provide  the  insurance  coverage  under  a  group insurance policy,  delivered in this  state,  in  lieu  of  the  issuance  of  a  converted  individual policy of insurance. Such individual policy, or group policy,  as the case may be is hereafter referred to as the converted policy. The  benefits  provided under the converted policy shall be those required by  subsection (f), (g), (h) or (i) hereof, whichever is applicable and,  in  the  event  of  termination  of the converted group policy of insurance,  each insured thereunder shall have a right of conversion to a  converted  individual policy of insurance.    (2)  The  insurer  shall  not  be required to issue a converted policy  covering any person if such person is covered for  similar  benefits  by  another  hospital  or  surgical  or  medical expense insurance policy or  hospital or medical service subscriber contract or medical  practice  or  other  prepayment plan or by any other plan or program or such person is  eligible for similar benefits, whether or not  covered  therefor,  under  any arrangement of coverage for individuals in a group, other than under  the  converted  policy,  whether  on  an  insured  or uninsured basis or  similar benefits are provided for or available to such  person  pursuant  to any statute; and the benefits provided or available under any of such  sources  which  together  with the benefits provided under the converted  policy  would  result  in  overinsurance  or  duplication  of   benefits  according to standards on file with the superintendent.    (3)  The  converted  policy  shall,  at  the option of the employee or  member, provide identical coverage for the dependents of  such  employee  or  member  who  were covered under the group policy. Provided, however,  that if the employee or member chooses the option of dependent  coverage  then  dependents  acquired after the permitted time to convert stated in  paragraph one of this subsection shall be added to the converted  family  policy  in  accordance  with the provisions of subsection (c) of section  thirty-two  hundred  sixteen  of  this  article  and   any   regulations  promulgated  or  guidelines  issued by the superintendent. The converted  policy need not provide benefits in excess of those  provided  for  such  persons  under  the  group  policy from which conversion is made and may  contain any exclusion or  benefit  limitation  contained  in  the  group  policy or customarily used in individual policies. The effective date of  the  individual's  coverage under the converted policy shall be the date  of the termination of the individual's insurance under the group  policy  as to those persons covered under the group policy.    (4)  The  converted  policy shall not exclude a pre-existing condition  not excluded by the group policy  but  may  provide  that  any  benefits  payable  thereunder  may  be  reduced by the amount of any such benefits  payable under the group policy after the termination of the individual's  insurance thereunder, and during the first  year  of  such  individual's  coverage  under  the  converted  policy  the  benefits payable under the  policy may be reduced so that they are not in excess of those that would  have been payable had the individual's insurance under the group  policy  remained  in effect. The converted policy may provide for termination of  coverage thereunder on any person when he is  or  could  be  covered  by  Medicare (subchapter XVIII of the federal Social Security Act, 42 U.S.C.  §§ 1395 et seq) by reason of age.(5)  If  delivery  of  an  individual  converted  policy is to be made  outside this state, it may be on such form as the insurer  may  then  be  offering  for such conversion in the jurisdiction where such delivery is  to be made.    (6)  (A)  A  converted  policy  may  include  a  provision whereby the  insurer, during the first two years of an  individual's  coverage  under  the  policy,  may request information in advance of any premium due date  of such policy of any person covered thereunder  as  to  whether  he  is  covered  for similar benefits by another hospital or surgical or medical  expense insurance policy  or  hospital  or  medical  service  subscriber  contract  or  medical  practice or other prepayment plan or by any other  plan or program or similar benefits are provided for, or  available  to,  such person pursuant to any statute.    (B)  If  any  such person is so covered or such statutory benefits are  provided or available, and such person fails to furnish the insurer  the  details  of such coverage within thirty-one days after such request, the  benefits payable under the converted policy with respect to such  person  may  be  based  on the hospital or surgical or medical expenses actually  incurred after excluding  expenses  to  the  extent  of  the  amount  of  benefits provided or available therefor from any of the sources referred  to in subparagraph (A) hereof.    (7) The conversion provision shall also be available upon the death of  the  employee or member, to the surviving spouse with respect to such of  the spouse and children as are then covered by  the  group  policy,  and  shall  be  available  to a child solely with respect to himself upon his  attaining the limiting age of coverage  under  the  group  policy  while  covered  as  a dependent thereunder. It shall also be available upon the  divorce or annulment of the marriage of the employee or member,  to  the  former spouse of such employee or member.    (8)  (A) Each certificate holder shall be given written notice of such  conversion privilege and its duration  within  fifteen  days  before  or  after  the  date of termination of group coverage, provided that if such  notice be given more than fifteen days but less than ninety  days  after  the  date  of  termination  of  group coverage, the time allowed for the  exercise  of  such  privilege  of  conversion  shall  be  extended   for  forty-five  days  after the giving of such notice. If such notice be not  given within  ninety  days  after  the  date  of  termination  of  group  coverage, the time allowed for the exercise of such conversion privilege  shall expire at the end of such ninety days.    (B) Written notice by the policyholder given to the certificate holder  or  mailed  to  the  certificate holder's last known address, or written  notice by the insurer be sent by first class  mail  to  the  certificate  holder at the last address furnished to the insurer by the policyholder,  shall  be  deemed full compliance with the provisions of this subsection  for the giving of notice.    (C) A group contract issued by an insurer may contain a  provision  to  the  effect  that  notice  of such conversion privilege and its duration  shall be given by the  policyholder  to  each  certificate  holder  upon  termination of his group coverage.    (9)  This  subsection  shall  not  apply to a group policy issued to a  policyholder whose principal activities are located outside  this  state  by  any  life insurance company organized and operated without profit to  any private shareholder or individual, and operated exclusively for  the  purpose  of  aiding and strengthening charitable, religious, missionary,  education or philanthropic institutions, by issuing insurance  contracts  only  to or for the benefit of such institutions, to individuals engaged  in the services of such institutions and to  members  of  the  immediate  families of such individuals.(10)  (A)  This  subsection shall not apply to a group policy insuring  persons employed in an establishment  located  outside  this  state  and  their  dependents  issued  by  a  life  insurance company which has been  organized  for  the  purpose  of  establishing  a  non-profit  voluntary  employee  beneficiary association to provide life, sickness, accident or  other benefits to eligible employees or their beneficiaries, is operated  exclusively for said purposes and without profit, direct or indirect, to  any private shareholder or individual, and is duly  exempt  from  income  taxation, pursuant to the federal Internal Revenue Code.    (B)  Notwithstanding  the  provisions  of subparagraph (A) hereof, any  resident of this state and his dependents who are insured under a  group  policy  providing  hospital or surgical expense insurance for other than  specific diseases or accident only which is issued by a  life  insurance  company organized as aforementioned, shall be entitled to the conversion  privileges specified in this subsection.    (11)  In  addition  to the right of conversion herein, the employee or  member insured under the policy shall at his option, as  an  alternative  to  conversion,  be  entitled  to  have his coverage continued under the  group policy in accordance with the conditions and limitations contained  in subsection (m) of this section, and have issued at  the  end  of  the  period  of  continuation  an individual conversion policy subject to the  terms of this subsection. The effective date for the  conversion  policy  shall  be the day following the termination of insurance under the group  policy, or if there is a continuation of coverage, on the day  following  the  end  of  the period of continuation. Notwithstanding the foregoing,  the superintendent may require conversion or continuation  of  insurance  under  conditions  as  set  forth  in  a regulation for insureds under a  policy issued in accordance with subparagraph (E) of  paragraph  one  of  subsection  (c) of section four thousand two hundred thirty-five of this  chapter.    (f) Any employee or  member  who  upon  becoming  entitled  to  obtain  coverage  under  a converted policy has attained age sixty, and has been  insured for at least  two  years  under  the  group  policy  immediately  preceding  the  date  the  employee or member first became entitled to a  converted policy shall have the privilege of obtaining such policy for a  premium computed at a rate which in any policy year shall not exceed one  hundred  twenty  percent  of  a  net  level  premium  approved  by   the  superintendent  and  determined,  according  to  the attained age of the  insured at the time of conversion and the plan of reimbursement elected,  on the basis of current experience of licensed insurers  providing  such  coverage  and  of  reasonable assumptions as to morbidity, mortality and  interest. Such net level premium  may  be  changed  in  accordance  with  experience  and  with the approval of the superintendent at intervals of  not more frequently  than  five  years.  Notwithstanding  the  foregoing  provisions  of  this subsection, nothing herein shall be construed so as  to avoid the requirements of open enrollment and community rating as set  forth elsewhere in this chapter.    (g) The conversion privilege shall,  if  the  group  insurance  policy  insures  the  employee  or member for basic hospital or surgical expense  insurance, or if the group insurance  policy  insures  the  employee  or  member for comprehensive medical expense insurance, entitle the employee  or  member to obtain coverage under a converted policy providing, at his  option, coverage under any one of the  following  plans  on  an  expense  incurred basis:    (1) Plan I.    (A)  hospital  room  and  board expense benefits of one hundred thirty  dollars per day for a maximum duration of twenty-one days,(B) miscellaneous hospital expense benefits of a maximum amount of one  thousand three hundred dollars, and    (C)  surgical  operation  expense benefits according to a one thousand  four hundred dollar maximum benefit schedule, or    (2) Plan II.    (A) hospital room and board expense benefits  of  two  hundred  thirty  dollars per day for a maximum duration of thirty days,    (B) miscellaneous hospital expense benefits of a maximum amount of two  thousand three hundred dollars, and    (C)  surgical  operation  expense benefits according to a two thousand  four hundred dollar maximum benefit schedule, or    (3) Plan III.    (A) hospital room and board expense benefits of three  hundred  thirty  dollars a day for a maximum duration of seventy days,    (B)  miscellaneous  hospital  benefits  of  a  maximum amount of three  thousand three hundred dollars, and    (C) surgical operation expense benefits according to a three  thousand  five hundred dollar maximum benefit schedule.    (h)  The  conversion  privilege  shall,  if the group insurance policy  insures the employee or member for major medical expense  insurance,  or  if  the  group  insurance  policy  insures  the  employee  or member for  comprehensive medical expense insurance, entitle the employee or  member  to  obtain  coverage  under  a  converted policy providing major medical  coverage under one of the following plans or one at least  as  favorable  to the covered persons:    (1) A maximum conforming to subparagraph (A) or (B) hereof:    (A)  A maximum payment of two hundred thousand dollars for all covered  medical expenses combined during the covered person's lifetime, with  an  annual  restoration on each January first while coverage is in force, up  to five thousand dollars of  the  amount  counted  against  the  maximum  benefit and not previously restored.    (B)  A  maximum  payment  of  two  hundred  thousand  dollars for each  unrelated injury or sickness.    (2) Payment of benefits  up  to  eighty  percent  of  covered  medical  expenses  which  are  in  excess of the deductible, except that when the  combined deductible and other out-of-pocket covered medical expenses not  reimbursed by any other hospital, surgical or medical insurance  policy,  or  hospital  or  medical subscriber contract, or other prepayment plan,  exceed two thousand dollars, then payment of benefits shall  be  at  one  hundred percent of covered medical expenses.    (3)  (A) A deductible which is the greater of one thousand dollars and  the benefits deductible.    (B) The term "benefits deductible", as used herein, means the value of  any benefits provided on an expense incurred basis  which  are  provided  with  respect  to  covered  medical  expenses  by  any  other  hospital,  surgical, or medical insurance policy or  hospital  or  medical  service  subscriber contract or medical practice or other prepayment plan, or any  other  plan  or  program whether on an insured or uninsured basis, or in  accordance with the requirements of any  statute  and,  if  pursuant  to  subsection (i) hereof, the converted policy provides both basic hospital  or surgical coverage and major medical coverage, the value of such basic  benefits.    (C)  The insurer may require that the deductible be satisfied during a  period of not less than three months.    (4) (A) The benefit period  shall  be  each  calendar  year  when  the  maximum  payment  is  determined  by  subparagraph  (A) of paragraph one  hereof or twenty-four months when the maximum payment is  determined  by  subparagraph (B) of paragraph one hereof.(B)  For  the  purpose  of  determining the benefits payable, the term  "covered medical expenses", as used above,  is  defined  as  the  actual  expense  incurred, provided however, for hospital room and board charges  an insurer may limit the maximum major medical benefit  payable  to  the  lesser  of the hospital's most common semi-private room and board charge  or three hundred thirty dollars per day and, in  the  case  of  surgical  charges,  an insurer may limit the maximum major medical benefit payable  to the lesser of seventy-five percent of the prevailing  reasonable  and  customary  charges  or  the  benefit payable pursuant to a four thousand  five hundred dollar maximum benefit schedule.    (i) The conversion privilege shall,  if  the  group  insurance  policy  insures  the  employee  or member for basic hospital or surgical expense  insurance as well as major medical expense insurance, make available the  plans of benefits set forth in subsections (g) and (h)  hereof.  At  the  option  of the insurer, such plans of benefits may be provided under one  policy.    (j) No policy of group or blanket accident and health insurance  shall  be  issued  as  excess coverage for volunteer firemen over and above the  coverage provided for pursuant to the volunteer  firemen's  benefit  law  unless  such  excess  policy provides for each of the types of coverages  set forth in subdivision one of section five of  such  law.  Any  excess  policy  which  does not contain such provisions shall be construed as if  such coverages were embodied therein.    (k) (1) (A) Every group policy delivered or  issued  for  delivery  in  this  state  which  provides coverage for in-patient hospital care shall  provide coverage for home care to residents in this state,  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 home care coverage shall be included at the inception of  all  new  policies and, with respect to all other policies, added at any  anniversary date of the policy subject to evidence of insurability.    (B) Such coverage may be subject to an annual deductible of  not  more  than  fifty  dollars for each person covered under the policy and may be  subject to a coinsurance provision which provides for  coverage  of  not  less  than  seventy-five  percent  of  the  reasonable  charges for such  services.    (C) Home care means the care and treatment of a covered person who  is  under the care of a physician but only if hospitalization or confinement  in  a  nursing  facility  as  defined in subchapter XVIII of the federal  Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been  required if home care was not provided, and the plan covering  the  home  health service is established and approved in writing by such physician.    (D)  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 and  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.    (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 under the contract if the covered person  had been hospitalized or confined  in  a  skilled  nursing  facility  asdefined  in  subchapter  XVIII  of  the  federal Social Security Act, 42  U.S.C. §§ 1395 et seq.    (E)  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 person covered under the contract; four hours  of home health aide service shall be considered as one home care visit.    (2) (A) Every insurer issuing a group policy delivered or  issued  for  delivery  in  this state which provides coverage for in-patient hospital  care shall include coverage for preadmission tests performed in hospital  facilities prior to scheduled surgery, 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.    (B)  Such  policy  shall  provide  benefits  for  tests  ordered  by a  physician which  are  performed  in  the  out-patient  facilities  of  a  hospital  as  a  planned  preliminary  to admission of the patient as an  in-patient for surgery in the same hospital, provided that:    (i) tests are necessary for and  consistent  with  the  diagnosis  and  treatment of the condition for which surgery is to be performed;    (ii)  reservations  for  a hospital bed and for an operating room were  made prior to the performance of the tests;    (iii) the surgery actually takes  place  within  seven  days  of  such  presurgical tests; and    (iv) the patient is physically present at the hospital for the tests.    (3)  Every group policy delivered or issued for delivery in this state  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 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.    (4) (A) Every group policy delivered or issued for  delivery  in  this  state  which provides coverage for inpatient hospital care shall include  coverage for services  to  treat  an  emergency  condition  provided  in  hospital  facilities,  except  that  this provision shall not apply to a  policy which cover 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) In this paragraph, an "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 (i) 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 (ii) serious impairment to such person's bodily functions;  (iii) serious dysfunction of any bodily organ or part of such person; or  (iv) serious disfigurement of such person.    (5) (A) * (i) Every group or blanket policy delivered  or  issued  for  delivery  in  this  state  which  provides hospital, surgical or medical  coverage shall include coverage for maternity care, including  hospital,  surgical  or  medical  care to the same extent that coverage is provided  for illness or disease under the policy. Such maternity  care  coverage,  other than coverage for perinatal complications, shall include inpatienthospital  coverage for mother and newborn for at least forty-eight hours  after childbirth for any delivery other than a  caesarean  section,  and  for  at  least ninety-six hours after 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 required to pay for  duplicative routine  services  actually  provided  by  both  a  licensed  midwife and a physician.    * NB Effective until October 28, 2010    * (i)  Every  group or blanket policy delivered or issued for delivery  in this state which provides  hospital,  surgical  or  medical  coverage  shall  include coverage for maternity care, including hospital, surgical  or medical care to the same extent that coverage is provided for illness  or disease under the policy. Such maternity care  coverage,  other  than  coverage  for  perinatal complications, shall include inpatient hospital  coverage for mother and newborn for at  least  forty-eight  hours  after  childbirth  for  any delivery other than a caesarean section, and for at  least ninety-six hours after 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    (ii)  Maternity  care  coverage shall also include, at minimum, parent  education, assistance and training in breast or bottle feeding, and  the  performance of any necessary maternal and newborn clinical assessments.    (iii)  The  mother shall have the option to be discharged earlier than  the time periods established in item (i) of this subparagraph.  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 policy. The policy 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  policy  and  subject  to  the  provisions  of this subparagraph, and not  subject to deductibles, coinsurance or copayments.    (B) Coverage provided under this  paragraph  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.    (6)  (A)  Every  group  policy issued or delivered in this state 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:    (i)  subject  to the provisions of subparagraph (C) of this paragraph,  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(ii)  provided,  further  however,  that  subject to the provisions of  subparagraph (C) of this paragraph,  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   paragraph,  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    (iii)  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 subparagraph (C) of this paragraph.    (B)  Every  group  policy  issued  or  delivered  in  this state 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:    (i) subject to the provisions of subparagraph (C) of  this  paragraph,  in  no  case  shall such coverage exclude surgical or medical procedures  which would correct malformation, disease or  dysfunction  resulting  in  infertility; and    (ii)  provided,  further  however,  that  subject to the provisions of  subparagraph (C) of this paragraph,  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 paragraph,  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    (iii)  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 subparagraph (C) of this paragraph.    (C)   Coverage  of  diagnostic  and  treatment  procedures,  including  prescription drugs, used in the diagnosis and treatment  of  infertility  as  required  by  subparagraphs  (A)  and (B) of this paragraph shall be  provided in accordance with the provisions of this subparagraph.    (i) 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.    (ii)  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 subparagraph.    (iii)   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.    (iv) 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 subparagraph "period of  not less than twelve months" shall be  determined  by  calculating  suchtime  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.    (v)  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 clause (vi) of this subparagraph.    (vi) 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 subparagraph, 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.    (7)(A)  Every  group  or  blanket accident and health insurance policy  issued or issued for delivery  in  this  state  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, the commissioner 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'sself-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 by  a  certified  diabetes  nurse   educator,   certified   nutritionist,   certified  dietitian  or  registered dietitian upon the referral of a physician or other  licensed  health  care  provider legally authorized to prescribe under title eight  of the education law. Education provided by the certified diabetes nurse  educator, certified  nutritionist,  certified  dietitian  or  registered  dietitian  may  be  limited  to  group  settings  wherever  practicable.  Coverage for self-management education and education  relating  to  diet  shall also include home visits when medically necessary.    (B) 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 policy.    (C)  This  paragraph  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 employed in more  than one state unless such policy is issued under  the  New  York  state  health  insurance  plan  established  under  article eleven of the civil  service law or issued to or through a local government.    (8) (A) Every group or blanket policy delivered or issued for delivery  in this state which provides coverage for inpatient hospital care  shall  provide  such coverage for such period as is determined by the attending  physician in consultation with the patient to be  medically  appropriate  for  such  covered  person  undergoing  a  lymph  node  dissection  or a  lumpectomy for the treatment of breast cancer or a mastectomy covered by  the policy. 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  policy.  Written  notice  of  the availability of such coverage shall be  delivered to the policyholder prior to  inception  of  such  policy  and  annually thereafter.    (B)  An  insurer  providing  coverage  under  this  paragraph  and any  participating entity through which the insurer  offers  health  services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll  or  to  renew coverage under the terms of the policy or vary the  terms of the policy for the purpose  or  with  the  effect  of  avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person  to accept less than the minimum protections available under this  paragraph;    (iii) penalize in any way or reduce or limit  the  compensation  of  a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph;    (iv)  provide  incentives  (monetary  or  otherwise)  to a health care  practitioner  relating  to  the  services  provided  pursuant  to   this  paragraph  intended  to  induce  or  have  the  effect  of inducing such  practitioner  to  provide  care  to  a  covered  person  in   a   manner  inconsistent with this paragraph; or    (v)  restrict  coverage  for any portion of a period within a hospital  length of stay required under  this  paragraph  in  a  manner  which  is  inconsistent  with  the  coverage  provided for any preceding portion of  such stay.    (C) The prohibitions in subparagraph (B) of this paragraph shall be in  addition to the  provisions  of  sections  three  thousand  two  hundredthirty-one and three thousand two hundred thirty-two of this article and  nothing  in  this subparagraph shall be construed to suspend, supersede,  amend or otherwise modify such sections.    (9)(A)  Every policy which provides medical, major medical, or similar  comprehensive-type coverage must provide coverage for a  second  medical  opinion  by  an  appropriate  specialist, including but not limited to a  specialist affiliated with a specialty care center for the treatment  of  cancer,  in the event of a positive or negative diagnosis of cancer or a  recurrence of cancer or a recommendation of a course  of  treatment  for  cancer, subject to the following:    (i)  In  the  case  of  a  policy that requires, or provides financial  incentives for, the insured to receive covered services from health care  providers participating in a provider network  maintained  by  or  under  contract  with  the  insurer,  the  policy  shall include coverage for a  second medical opinion from a  non-participating  specialist,  including  but  not limited to a specialist affiliated with a specialty care center  for the treatment of cancer, when the  attending  physician  provides  a  written  referral  to  a  non-participating specialist, at no additional  cost to the insured  beyond  what  such  insured  would  have  paid  for  services  from a participating appropriate specialist. Provided, however  that nothing herein shall impair an insured's rights (if any) under  the  policy  to  obtain  the  second medical opinion from a non-participating  specialist without  a  written  referral,  subject  to  the  payment  of  additional  coinsurance  (if  any)  required  by the policy for services  provided by non-participating providers. The  insurer  shall  compensate  the  non-participating specialist at the usual, customary and reasonable  rate, or at a rate listed on a fee schedule filed and  approved  by  the  superintendent which provides a comparable level of reimbursement.    (ii)  In  the  case  of  a  policy  that  does  not  provide financial  incentives for, and does not require, the  insured  to  receive  covered  services  from health care providers participating in a provider network  maintained by or under contract  with  the  insurer,  the  policy  shall  include  coverage  for  a second medical opinion from a specialist at no  additional cost to the insured beyond what the insured would  have  paid  for comparable services covered under the policy.    (iii)   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  policy, and, where applicable, consistent with the provisions of clauses  (i) and (ii) of this subparagraph.    Nothing in this paragraph shall eliminate  or  diminish  an  insurer's  obligation  to comply with the provisions of section four thousand eight  hundred four of this chapter where applicable.  Written  notice  of  the  availability  of  such  coverage  shall be delivered to the policyholder  prior to the inception of such policy and annually thereafter.    (B) An  insurer  providing  coverage  under  this  paragraph  and  any  participating  entity  through  which  an insurer offers health services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll or to renew coverage under the terms of the policy  or  vary  the  terms  of  the  policy  for  the  purpose or with the effect of avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person to accept less than the minimum protections available under  this  paragraph;    (iii)  penalize  in  any  way or reduce or limit the compensation of a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph; or(iv) provide incentives (monetary  or  otherwise)  to  a  health  care  practitioner   relating  to  the  coverage  provided  pursuant  to  this  paragraph intended to  induce  or  have  the  effect  of  inducing  such  practitioner   to   provide  care  to  a  covered  person  in  a  manner  inconsistent with this paragraph.    (C) The prohibitions in subparagraph (B) of this paragraph shall be in  addition  to  the  provisions  of  sections  three  thousand two hundred  thirty-one and three thousand two hundred thirty-two of this article and  nothing in this subparagraph shall be construed to  suspend,  supersede,  amend or otherwise modify such sections.    (10)(A) Every group or blanket policy delivered or issued for delivery  in  this  state  which  provides  medical,  major  medical,  or  similar  comprehensive-type coverage shall provide  the  following  coverage  for  breast reconstruction surgery after a mastectomy:    (i) all stages of reconstruction of the breast on which the mastectomy  has been performed; and    (ii)  surgery  and  reconstruction  of  the  other breast to produce a  symmetrical appearance;  in the manner determined by the attending physician and the  patient  to  be  appropriate.  Such coverage may be subject to annual deductibles and  coinsurance  provisions  as   may   be   deemed   appropriate   by   the  superintendent  and  as  are consistent with those established for other  benefits within a given policy. Written notice of  the  availability  of  such  coverage shall be delivered to the policyholder prior to inception  of such policy and annually thereafter.    (B) An  insurer  providing  coverage  under  this  paragraph  and  any  participating  entity  through  which the insurer offers health services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll or to renew coverage under the terms of the policy  or  vary  the  terms  of  the  policy  for  the  purpose or with the effect of avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person to accept less than the minimum protections available under  this  paragraph;    (iii)  penalize  in  any  way or reduce or limit the compensation of a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph;    (iv) provide incentives (monetary  or  otherwise)  to  a  health  care  practitioner   relating  to  the  services  provided  pursuant  to  this  paragraph intended to  induce  or  have  the  effect  of  inducing  such  practitioner   to   provide  care  to  a  covered  person  in  a  manner  inconsistent with this paragraph; or    (v) restrict coverage for any portion of a period  within  a  hospital  length  of  stay  required  under  this  paragraph  in a manner which is  inconsistent with the coverage provided for  any  preceding  portion  of  such stay.    (C)  The  prohibitions  in  this paragraph shall be in addition to the  provisions of sections three thousand two hundred thirty-one  and  three  thousand  two  hundred  thirty-two  of  this article and nothing in this  paragraph shall be construed to suspend, supersede, amend  or  otherwise  modify such sections.    * (11)  Every  policy  which  provides coverage for prescription drugs  shall include coverage for the cost of enteral formulas for home use for  which a  physician  or  other  licensed  health  care  provider  legally  authorized  to  prescribe  under  title  eight  of the education law has  issued a written order. Such written order shall state that the  enteral  formula  is clearly medically necessary and has been proven effective asa disease-specific treatment regimen for those individuals  who  are  or  will  become  malnourished  or  suffer  from  disorders,  which  if left  untreated, cause chronic  physical  disability,  mental  retardation  or  death.  Specific  diseases  for  which enteral formulas have been proven  effective shall include, but are not limited to, inherited  diseases  of  amino-acid or organic acid metabolism; Crohn's Disease; gastroesophageal  reflux  with  failure  to thrive; disorders of gastrointestinal motility  such as chronic intestinal pseudo-obstruction; and multiple, severe food  allergies which if left untreated  will  cause  malnourishment,  chronic  physical disability, mental retardation or death. Enteral formulas which  are  medically  necessary and taken under written order from a physician  for the treatment of  specific  diseases  shall  be  distinguished  from  nutritional supplements taken electively. Coverage for certain inherited  diseases  of  amino  acid  and  organic  acid  metabolism  shall include  modified solid food products that  are  low  protein  or  which  contain  modified  protein  which  are medically necessary, and such coverage for  such modified solid food products for  any  calendar  year  or  for  any  continuous  period of twelve months for any insured individual shall not  exceed two thousand five hundred dollars.    * NB There are 2 par (11)'s    * (11)(A) Every policy which is a "managed care product" as defined in  subparagraph (D) of this paragraph that includes coverage for  physician  services  in  a physician's office, and every policy which is a "managed  care product" that provides major medical or similar  comprehensive-type  coverage  shall  include  coverage  for chiropractic care, as defined in  section six thousand  five  hundred  fifty-one  of  the  education  law,  provided  by  a  doctor of chiropractic licensed pursuant to article one  hundred  thirty-two  of  the  education  law,  in  connection  with  the  detection  or  correction  by  manual  or mechanical means of structural  imbalance, distortion or subluxation in the human body for  the  purpose  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. However, chiropractic care  and services may be subject to  reasonable  deductible,  co-payment  and  co-insurance  amounts,  reasonable fee or benefit limits, and reasonable  utilization review, provided that any such amounts, limits  and  review:  (a)  shall  not  function to direct treatment in a manner discriminative  against chiropractic care, and (b) individually and  collectively  shall  be  no  more  restrictive than those applicable under the same policy to  care  or  services  provided  by  other  health  professionals  in   the  diagnosis,  treatment  and management of the same or similar conditions,  injuries,  complaints,  disorders  or  ailments,   even   if   differing  nomenclature  is  used  to  describe  the  condition, injury, complaint,  disorder or ailment. Nothing herein  contained  shall  be  construed  as  impeding  or preventing either the provision or coverage of chiropractic  care and services by duly licensed doctors of chiropractic,  within  the  lawful scope of chiropractic practice, in hospital facilities on a staff  or employee basis.    (C)  Every  policy which includes coverage for physician services in a  physician's office, and every policy which  provides  major  medical  or  similar comprehensive-type coverage, other than a "managed care product"  as defined in subparagraph (D) of this paragraph, shall provide coverage  for  chiropractic  care, as defined in section six thousand five hundred  fifty-one of the education law, provided by  a  doctor  of  chiropractic  licensed  pursuant  to  article  one hundred thirty-two of the education  law, in connection  with  the  detection  or  correction  by  manual  or  mechanical  means  of structural imbalance, distortion or subluxation in  the human body for the purpose of removing nerve interference,  and  theeffects  thereof, where such interference is the result of or related to  distortion, misalignment or subluxation of or in the  vertebral  column.  However,  chiropractic  care  and  services may be subject to reasonable  deductible,  co-payment  and  co-insurance  amounts,  reasonable  fee or  benefit limits, and reasonable utilization  review,  provided  that  any  such  amounts,  limits  and  review:  (a)  shall  not function to direct  treatment in a manner discriminative against chiropractic care, and  (b)  individually  and  collectively  shall be no more restrictive that those  applicable under the same policy to care or services provided  by  other  health  professionals  in the diagnosis, treatment and management of the  same or similar conditions, injuries, complaints, disorders or ailments,  even if differing  nomenclature  is  used  to  describe  the  condition,  injury,  complaint,  disorder or ailment. Nothing herein contained shall  be construed as impeding or preventing either the provision or  coverage  of   chiropractic   care  and  services  by  duly  licensed  doctors  of  chiropractic, within the  lawful  scope  of  chiropractic  practice,  in  hospital facilities on a staff or employee basis.    (D)  For  purposes  of  this paragraph, a "managed care product" shall  mean a policy which requires that medical or other health care  services  covered  under  the  policy,  other  than  emergency  care  services, be  provided by, or pursuant to a referral from, a  primary  care  provider,  and  that services provided pursuant to such a referral be rendered by a  health  care  provider  participating  in  the  insurer's  managed  care  provider  network.  In  addition, a managed care product shall also mean  the in-network portion of a contract  which  requires  that  medical  or  other  health  care  services  covered  under  the  contract, other than  emergency care services, be provided by, or pursuant to a referral from,  a primary care provider, and that services provided pursuant to  such  a  referral  be  rendered  by  a  health care provider participating in the  insurer's managed care provider network, in order for the insured to  be  entitled to the maximum reimbursement under the contract.    (E)  The  coverage required by this paragraph shall not be abridged by  any regulation promulgated by the su	
	
	
	
	

State Codes and Statutes

Statutes > New-york > Isc > Article-32 > 3221

§  3221.  Group  or  blanket  accident  and health insurance policies;  standard provisions. (a) No policy of  group  or  blanket  accident  and  health  insurance shall, except as provided in subsection (d) hereof, be  delivered or issued for delivery in this state  unless  it  contains  in  substance the following provisions or provisions which in the opinion of  the   superintendent   are   more  favorable  to  the  holders  of  such  certificates or not less favorable to the holders of  such  certificates  and   more  favorable  to  policyholders,  provided  however,  that  the  provisions set forth in paragraphs six and thirteen of  this  subsection  shall  not  be  applicable  to  any  such  policy  which  is issued to a  policyholder in accordance with subparagraph (E)  of  paragraph  one  of  subsection  (c) of section four thousand two hundred thirty-five of this  chapter:    (1) (A) No statement made  by  the  person  insured  shall  avoid  the  insurance  or  reduce  benefits thereunder unless contained in a written  instrument signed by the person insured.    (B) All statements contained in any such written instrument  shall  be  deemed representations and not warranties.    (2)  That  no agent has authority to change the policy or waive any of  its provisions and that no change in the policy shall  be  valid  unless  approved  by  an  officer of the insurer and evidenced by endorsement on  the policy, or by amendment to the policy signed by the policyholder and  the insurer.    (3) That all new employees or new members in the classes eligible  for  insurance must be added to such class for which they are eligible.    (4)  That  all  premiums due under the policy shall be remitted by the  employer or employers of the persons insured or by some other designated  person acting on behalf of the association  or  group  insured,  to  the  insurer  on or before the due date thereof, with such period of grace as  may be specified therein.    (5) The conditions under which the insurer may decline  to  renew  the  policy.    (6)  That  the insurer shall issue either to the employer or person in  whose name such policy is issued, for delivery to  each  member  of  the  insured  group,  a certificate setting forth in summary form a statement  of the essential features of the insurance coverage and in substance the  following provisions of this subsection.    (7) The ages,  to  which  the  insurance  provided  therein  shall  be  limited;  and  the ages, for which additional restrictions are placed on  benefits, and the additional restrictions placed on the benefits at such  ages.    (8) That written notice of claim must be given to the  insurer  within  twenty  days after the occurrence or commencement of any loss covered by  the policy. Failure to give notice within such time shall not invalidate  or reduce any claim if it shall be shown not  to  have  been  reasonably  possible  to  give  such notice and that notice was given as soon as was  reasonably possible.    * (9) That in the case of claim  for  loss  of  time  for  disability,  written  proof  of  such  loss  must  be furnished to the insurer within  thirty days after the commencement of the period for which  the  insurer  is liable, and that subsequent written proofs of the continuance of such  disability  must  be  furnished  to the insurer at such intervals as the  insurer may reasonably require, and that in the case of  claim  for  any  other  loss, written proof of such loss must be furnished to the insurer  within ninety days after the date of such loss. Failure to furnish  such  proof  within  such  time shall not invalidate or reduce any claim if it  shall be shown not to have been  reasonably  possible  to  furnish  suchproof  within  such  time,  provided such proof was furnished as soon as  reasonably possible.    * NB Effective until January 1, 2011    * (9)  That  in  the  case  of  claim for loss of time for disability,  written proof of such loss must  be  furnished  to  the  insurer  within  thirty  days  after the commencement of the period for which the insurer  is liable, and that subsequent written proofs of the continuance of such  disability must be furnished to the insurer at  such  intervals  as  the  insurer  may  reasonably  require, and that in the case of claim for any  other loss, written proof of such loss must be furnished to the  insurer  within  one  hundred twenty days after the date of such loss. Failure to  furnish such proof within such time shall not invalidate or  reduce  any  claim  if  it  shall  be  shown  not to have been reasonably possible to  furnish such proof within such time, provided such proof  was  furnished  as soon as reasonably possible.    * NB Effective January 1, 2011    (10)  That  the  insurer will furnish to the person making claim or to  the policyholder for delivery to such person such forms as  are  usually  furnished  by  it  for  filing  proof  of  loss.  If  such forms are not  furnished before the  expiration  of  fifteen  days  after  the  insurer  receives  notice  of  any claim under the policy, the person making such  claim shall be deemed to have complied  with  the  requirements  of  the  policy  as to proof of loss upon submitting within the time fixed in the  policy for filing proof of loss, written proof covering the  occurrence,  character and extent of the loss for which claim is made.    (11)  That the insurer shall have the right and opportunity to examine  the person of the individual for whom claim is made when and so often as  it may reasonably require during the pendency of claim under the  policy  and  also  the right and opportunity to make an autopsy in case of death  where it is not prohibited by law.    (12) That benefits payable under the policy other  than  benefits  for  loss  of  time will be payable not more than sixty days after receipt of  proof, and that, subject to due  proof  of  loss  all  accrued  benefits  payable  under  the  policy  for  loss  of  time  will  be paid not less  frequently than monthly during the continuance of the period  for  which  the  insurer  is  liable,  and  that any balance remaining unpaid at the  termination of such period will be paid immediately upon receipt of such  proof.    (13) That indemnity for loss of life of  the  insured  is  payable  in  accordance  with  subsection  (e)  of  section four thousand two hundred  thirty-five of this chapter; and  that  all  other  indemnities  of  the  policy  are  payable to the insured, except as may be otherwise provided  in accordance with  such  subsection;  and  that  if  a  beneficiary  is  designated,  the  consent  of  the beneficiary shall not be requisite to  change of beneficiary,  or  to  any  other  changes  in  the  policy  or  certificate, except as may be specifically provided by the policy.    (14) That no action at law or in equity shall be brought to recover on  the policy prior to the expiration of sixty days after proof of loss has  been filed in accordance with the requirements of the policy and that no  such action shall be brought after the expiration of two years following  the time such proof of loss is required by the policy.    (15)  Any policy and certificate, other than one issued in fulfillment  of the continuing care responsibilities of an operator of  a  continuing  care  retirement  community  in accordance with article forty-six of the  public health law, made available because of residence in  a  particular  facility,  housing development, or community shall contain the following  notice in twelve point type in bold face on the first page:"NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF  A CONTINUING CARE RETIREMENT CONTRACT.  AVAILABILITY  OF  THIS  COVERAGE  WILL  NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT  COMMUNITY."    * (16)  No policy delivered or issued for delivery in this state which  provides coverage for prescription drugs  and  for  which  cost-sharing,  deductibles  or  co-insurance  obligations are determined by category of  prescription   drugs   shall   impose   cost-sharing,   deductibles   or  co-insurance  obligations  for  any  prescription  drug that exceeds the  dollar amount of cost-sharing, deductibles or  co-insurance  obligations  for non-preferred brand drugs or its equivalent (or brand drugs if there  is no non-preferred brand drug category).    * NB Effective October 31, 2010    (b)  No  such policy shall be delivered or issued for delivery in this  state unless a schedule of the premium rates  pertaining  to  such  form  shall have been filed with the superintendent.    (c)  Any  portion of any such policy, which purports, by reason of the  circumstances under which a loss is incurred,  to  reduce  any  benefits  promised  thereunder  to  an amount less than that provided for the same  loss occurring under ordinary circumstances, shall be printed,  in  such  policy  and in each certificate issued thereunder, in bold face type and  with greater prominence than any other  portion  of  the  text  of  such  policy  or  certificate; and all other exceptions of the policy shall be  printed in the policy and in the certificate, with the  same  prominence  as  the  benefits  to  which they apply. If any such policy contains any  provision which affects the liability of the  insurer,  on  the  grounds  stated  in subparagraph (J) or (K) of paragraph two of subsection (d) of  section three thousand two hundred sixteen of this  article,  then  such  provision  shall  be contained in the policy and certificate in the form  set forth in such section.    (d) (1) The superintendent may approve any form of certificate  to  be  issued  under  a blanket accident and health insurance policy as defined  in section four thousand two hundred thirty-seven of this chapter, which  omits or modifies any of the provisions  hereinbefore  required,  if  he  deems  such  omission or modification suitable for the character of such  insurance and not unjust to the persons insured thereunder.    (2) The superintendent may approve any form of group insurance  policy  providing  disability  benefits to be issued pursuant to article nine of  the workers' compensation  law  which  omits  or  modifies  any  of  the  provisions  hereinbefore  required,  if such omission or modification is  not inconsistent with the provisions of such article nine and  he  deems  such  omission  or  modification  suitable  for  the  character  of such  insurance and not unjust to the persons insured thereunder.    (3) The superintendent may also approve any form  of  group  insurance  policy   to  be  issued  to  a  social  services  district  pursuant  to  subdivision two of section three hundred  sixty-seven-a  of  the  social  services law, which omits or modifies any of the provisions hereinbefore  required,  if  he  deems  such omission or modification suitable for the  character of such insurance.    (e)  (1)  A  group  policy  providing  hospital  or  surgical  expense  insurance  for  other  than  specific  diseases  or accident only, shall  provide that if the insurance on an employee or member insured under the  group policy ceases because of  termination  of  (I)  employment  or  of  membership  in  the  class  or  classes  eligible for coverage under the  policy or (II)  the  policy,  for  any  reason  whatsoever,  unless  the  policyholder  has  replaced the group policy with similar and continuous  coverage for the  same  group  whether  insured  or  self-insured,  such  employee  or  member  who has been insured under the group policy for atleast three months shall be entitled  to  have  issued  to  him  by  the  insurer  without  evidence  of insurability upon application made to the  insurer within forty-five days after such termination,  and  payment  of  the  quarterly,  or,  at  the  option  of the employee or member, a less  frequent premium applicable to the class of risk  to  which  the  person  belongs,  the  age of such person, and the form and amount of insurance,  an individual policy of insurance. The insurer may, at its option  elect  to  provide  the  insurance  coverage  under  a  group insurance policy,  delivered in this  state,  in  lieu  of  the  issuance  of  a  converted  individual policy of insurance. Such individual policy, or group policy,  as the case may be is hereafter referred to as the converted policy. The  benefits  provided under the converted policy shall be those required by  subsection (f), (g), (h) or (i) hereof, whichever is applicable and,  in  the  event  of  termination  of the converted group policy of insurance,  each insured thereunder shall have a right of conversion to a  converted  individual policy of insurance.    (2)  The  insurer  shall  not  be required to issue a converted policy  covering any person if such person is covered for  similar  benefits  by  another  hospital  or  surgical  or  medical expense insurance policy or  hospital or medical service subscriber contract or medical  practice  or  other  prepayment plan or by any other plan or program or such person is  eligible for similar benefits, whether or not  covered  therefor,  under  any arrangement of coverage for individuals in a group, other than under  the  converted  policy,  whether  on  an  insured  or uninsured basis or  similar benefits are provided for or available to such  person  pursuant  to any statute; and the benefits provided or available under any of such  sources  which  together  with the benefits provided under the converted  policy  would  result  in  overinsurance  or  duplication  of   benefits  according to standards on file with the superintendent.    (3)  The  converted  policy  shall,  at  the option of the employee or  member, provide identical coverage for the dependents of  such  employee  or  member  who  were covered under the group policy. Provided, however,  that if the employee or member chooses the option of dependent  coverage  then  dependents  acquired after the permitted time to convert stated in  paragraph one of this subsection shall be added to the converted  family  policy  in  accordance  with the provisions of subsection (c) of section  thirty-two  hundred  sixteen  of  this  article  and   any   regulations  promulgated  or  guidelines  issued by the superintendent. The converted  policy need not provide benefits in excess of those  provided  for  such  persons  under  the  group  policy from which conversion is made and may  contain any exclusion or  benefit  limitation  contained  in  the  group  policy or customarily used in individual policies. The effective date of  the  individual's  coverage under the converted policy shall be the date  of the termination of the individual's insurance under the group  policy  as to those persons covered under the group policy.    (4)  The  converted  policy shall not exclude a pre-existing condition  not excluded by the group policy  but  may  provide  that  any  benefits  payable  thereunder  may  be  reduced by the amount of any such benefits  payable under the group policy after the termination of the individual's  insurance thereunder, and during the first  year  of  such  individual's  coverage  under  the  converted  policy  the  benefits payable under the  policy may be reduced so that they are not in excess of those that would  have been payable had the individual's insurance under the group  policy  remained  in effect. The converted policy may provide for termination of  coverage thereunder on any person when he is  or  could  be  covered  by  Medicare (subchapter XVIII of the federal Social Security Act, 42 U.S.C.  §§ 1395 et seq) by reason of age.(5)  If  delivery  of  an  individual  converted  policy is to be made  outside this state, it may be on such form as the insurer  may  then  be  offering  for such conversion in the jurisdiction where such delivery is  to be made.    (6)  (A)  A  converted  policy  may  include  a  provision whereby the  insurer, during the first two years of an  individual's  coverage  under  the  policy,  may request information in advance of any premium due date  of such policy of any person covered thereunder  as  to  whether  he  is  covered  for similar benefits by another hospital or surgical or medical  expense insurance policy  or  hospital  or  medical  service  subscriber  contract  or  medical  practice or other prepayment plan or by any other  plan or program or similar benefits are provided for, or  available  to,  such person pursuant to any statute.    (B)  If  any  such person is so covered or such statutory benefits are  provided or available, and such person fails to furnish the insurer  the  details  of such coverage within thirty-one days after such request, the  benefits payable under the converted policy with respect to such  person  may  be  based  on the hospital or surgical or medical expenses actually  incurred after excluding  expenses  to  the  extent  of  the  amount  of  benefits provided or available therefor from any of the sources referred  to in subparagraph (A) hereof.    (7) The conversion provision shall also be available upon the death of  the  employee or member, to the surviving spouse with respect to such of  the spouse and children as are then covered by  the  group  policy,  and  shall  be  available  to a child solely with respect to himself upon his  attaining the limiting age of coverage  under  the  group  policy  while  covered  as  a dependent thereunder. It shall also be available upon the  divorce or annulment of the marriage of the employee or member,  to  the  former spouse of such employee or member.    (8)  (A) Each certificate holder shall be given written notice of such  conversion privilege and its duration  within  fifteen  days  before  or  after  the  date of termination of group coverage, provided that if such  notice be given more than fifteen days but less than ninety  days  after  the  date  of  termination  of  group coverage, the time allowed for the  exercise  of  such  privilege  of  conversion  shall  be  extended   for  forty-five  days  after the giving of such notice. If such notice be not  given within  ninety  days  after  the  date  of  termination  of  group  coverage, the time allowed for the exercise of such conversion privilege  shall expire at the end of such ninety days.    (B) Written notice by the policyholder given to the certificate holder  or  mailed  to  the  certificate holder's last known address, or written  notice by the insurer be sent by first class  mail  to  the  certificate  holder at the last address furnished to the insurer by the policyholder,  shall  be  deemed full compliance with the provisions of this subsection  for the giving of notice.    (C) A group contract issued by an insurer may contain a  provision  to  the  effect  that  notice  of such conversion privilege and its duration  shall be given by the  policyholder  to  each  certificate  holder  upon  termination of his group coverage.    (9)  This  subsection  shall  not  apply to a group policy issued to a  policyholder whose principal activities are located outside  this  state  by  any  life insurance company organized and operated without profit to  any private shareholder or individual, and operated exclusively for  the  purpose  of  aiding and strengthening charitable, religious, missionary,  education or philanthropic institutions, by issuing insurance  contracts  only  to or for the benefit of such institutions, to individuals engaged  in the services of such institutions and to  members  of  the  immediate  families of such individuals.(10)  (A)  This  subsection shall not apply to a group policy insuring  persons employed in an establishment  located  outside  this  state  and  their  dependents  issued  by  a  life  insurance company which has been  organized  for  the  purpose  of  establishing  a  non-profit  voluntary  employee  beneficiary association to provide life, sickness, accident or  other benefits to eligible employees or their beneficiaries, is operated  exclusively for said purposes and without profit, direct or indirect, to  any private shareholder or individual, and is duly  exempt  from  income  taxation, pursuant to the federal Internal Revenue Code.    (B)  Notwithstanding  the  provisions  of subparagraph (A) hereof, any  resident of this state and his dependents who are insured under a  group  policy  providing  hospital or surgical expense insurance for other than  specific diseases or accident only which is issued by a  life  insurance  company organized as aforementioned, shall be entitled to the conversion  privileges specified in this subsection.    (11)  In  addition  to the right of conversion herein, the employee or  member insured under the policy shall at his option, as  an  alternative  to  conversion,  be  entitled  to  have his coverage continued under the  group policy in accordance with the conditions and limitations contained  in subsection (m) of this section, and have issued at  the  end  of  the  period  of  continuation  an individual conversion policy subject to the  terms of this subsection. The effective date for the  conversion  policy  shall  be the day following the termination of insurance under the group  policy, or if there is a continuation of coverage, on the day  following  the  end  of  the period of continuation. Notwithstanding the foregoing,  the superintendent may require conversion or continuation  of  insurance  under  conditions  as  set  forth  in  a regulation for insureds under a  policy issued in accordance with subparagraph (E) of  paragraph  one  of  subsection  (c) of section four thousand two hundred thirty-five of this  chapter.    (f) Any employee or  member  who  upon  becoming  entitled  to  obtain  coverage  under  a converted policy has attained age sixty, and has been  insured for at least  two  years  under  the  group  policy  immediately  preceding  the  date  the  employee or member first became entitled to a  converted policy shall have the privilege of obtaining such policy for a  premium computed at a rate which in any policy year shall not exceed one  hundred  twenty  percent  of  a  net  level  premium  approved  by   the  superintendent  and  determined,  according  to  the attained age of the  insured at the time of conversion and the plan of reimbursement elected,  on the basis of current experience of licensed insurers  providing  such  coverage  and  of  reasonable assumptions as to morbidity, mortality and  interest. Such net level premium  may  be  changed  in  accordance  with  experience  and  with the approval of the superintendent at intervals of  not more frequently  than  five  years.  Notwithstanding  the  foregoing  provisions  of  this subsection, nothing herein shall be construed so as  to avoid the requirements of open enrollment and community rating as set  forth elsewhere in this chapter.    (g) The conversion privilege shall,  if  the  group  insurance  policy  insures  the  employee  or member for basic hospital or surgical expense  insurance, or if the group insurance  policy  insures  the  employee  or  member for comprehensive medical expense insurance, entitle the employee  or  member to obtain coverage under a converted policy providing, at his  option, coverage under any one of the  following  plans  on  an  expense  incurred basis:    (1) Plan I.    (A)  hospital  room  and  board expense benefits of one hundred thirty  dollars per day for a maximum duration of twenty-one days,(B) miscellaneous hospital expense benefits of a maximum amount of one  thousand three hundred dollars, and    (C)  surgical  operation  expense benefits according to a one thousand  four hundred dollar maximum benefit schedule, or    (2) Plan II.    (A) hospital room and board expense benefits  of  two  hundred  thirty  dollars per day for a maximum duration of thirty days,    (B) miscellaneous hospital expense benefits of a maximum amount of two  thousand three hundred dollars, and    (C)  surgical  operation  expense benefits according to a two thousand  four hundred dollar maximum benefit schedule, or    (3) Plan III.    (A) hospital room and board expense benefits of three  hundred  thirty  dollars a day for a maximum duration of seventy days,    (B)  miscellaneous  hospital  benefits  of  a  maximum amount of three  thousand three hundred dollars, and    (C) surgical operation expense benefits according to a three  thousand  five hundred dollar maximum benefit schedule.    (h)  The  conversion  privilege  shall,  if the group insurance policy  insures the employee or member for major medical expense  insurance,  or  if  the  group  insurance  policy  insures  the  employee  or member for  comprehensive medical expense insurance, entitle the employee or  member  to  obtain  coverage  under  a  converted policy providing major medical  coverage under one of the following plans or one at least  as  favorable  to the covered persons:    (1) A maximum conforming to subparagraph (A) or (B) hereof:    (A)  A maximum payment of two hundred thousand dollars for all covered  medical expenses combined during the covered person's lifetime, with  an  annual  restoration on each January first while coverage is in force, up  to five thousand dollars of  the  amount  counted  against  the  maximum  benefit and not previously restored.    (B)  A  maximum  payment  of  two  hundred  thousand  dollars for each  unrelated injury or sickness.    (2) Payment of benefits  up  to  eighty  percent  of  covered  medical  expenses  which  are  in  excess of the deductible, except that when the  combined deductible and other out-of-pocket covered medical expenses not  reimbursed by any other hospital, surgical or medical insurance  policy,  or  hospital  or  medical subscriber contract, or other prepayment plan,  exceed two thousand dollars, then payment of benefits shall  be  at  one  hundred percent of covered medical expenses.    (3)  (A) A deductible which is the greater of one thousand dollars and  the benefits deductible.    (B) The term "benefits deductible", as used herein, means the value of  any benefits provided on an expense incurred basis  which  are  provided  with  respect  to  covered  medical  expenses  by  any  other  hospital,  surgical, or medical insurance policy or  hospital  or  medical  service  subscriber contract or medical practice or other prepayment plan, or any  other  plan  or  program whether on an insured or uninsured basis, or in  accordance with the requirements of any  statute  and,  if  pursuant  to  subsection (i) hereof, the converted policy provides both basic hospital  or surgical coverage and major medical coverage, the value of such basic  benefits.    (C)  The insurer may require that the deductible be satisfied during a  period of not less than three months.    (4) (A) The benefit period  shall  be  each  calendar  year  when  the  maximum  payment  is  determined  by  subparagraph  (A) of paragraph one  hereof or twenty-four months when the maximum payment is  determined  by  subparagraph (B) of paragraph one hereof.(B)  For  the  purpose  of  determining the benefits payable, the term  "covered medical expenses", as used above,  is  defined  as  the  actual  expense  incurred, provided however, for hospital room and board charges  an insurer may limit the maximum major medical benefit  payable  to  the  lesser  of the hospital's most common semi-private room and board charge  or three hundred thirty dollars per day and, in  the  case  of  surgical  charges,  an insurer may limit the maximum major medical benefit payable  to the lesser of seventy-five percent of the prevailing  reasonable  and  customary  charges  or  the  benefit payable pursuant to a four thousand  five hundred dollar maximum benefit schedule.    (i) The conversion privilege shall,  if  the  group  insurance  policy  insures  the  employee  or member for basic hospital or surgical expense  insurance as well as major medical expense insurance, make available the  plans of benefits set forth in subsections (g) and (h)  hereof.  At  the  option  of the insurer, such plans of benefits may be provided under one  policy.    (j) No policy of group or blanket accident and health insurance  shall  be  issued  as  excess coverage for volunteer firemen over and above the  coverage provided for pursuant to the volunteer  firemen's  benefit  law  unless  such  excess  policy provides for each of the types of coverages  set forth in subdivision one of section five of  such  law.  Any  excess  policy  which  does not contain such provisions shall be construed as if  such coverages were embodied therein.    (k) (1) (A) Every group policy delivered or  issued  for  delivery  in  this  state  which  provides coverage for in-patient hospital care shall  provide coverage for home care to residents in this state,  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 home care coverage shall be included at the inception of  all  new  policies and, with respect to all other policies, added at any  anniversary date of the policy subject to evidence of insurability.    (B) Such coverage may be subject to an annual deductible of  not  more  than  fifty  dollars for each person covered under the policy and may be  subject to a coinsurance provision which provides for  coverage  of  not  less  than  seventy-five  percent  of  the  reasonable  charges for such  services.    (C) Home care means the care and treatment of a covered person who  is  under the care of a physician but only if hospitalization or confinement  in  a  nursing  facility  as  defined in subchapter XVIII of the federal  Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been  required if home care was not provided, and the plan covering  the  home  health service is established and approved in writing by such physician.    (D)  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 and  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.    (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 under the contract if the covered person  had been hospitalized or confined  in  a  skilled  nursing  facility  asdefined  in  subchapter  XVIII  of  the  federal Social Security Act, 42  U.S.C. §§ 1395 et seq.    (E)  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 person covered under the contract; four hours  of home health aide service shall be considered as one home care visit.    (2) (A) Every insurer issuing a group policy delivered or  issued  for  delivery  in  this state which provides coverage for in-patient hospital  care shall include coverage for preadmission tests performed in hospital  facilities prior to scheduled surgery, 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.    (B)  Such  policy  shall  provide  benefits  for  tests  ordered  by a  physician which  are  performed  in  the  out-patient  facilities  of  a  hospital  as  a  planned  preliminary  to admission of the patient as an  in-patient for surgery in the same hospital, provided that:    (i) tests are necessary for and  consistent  with  the  diagnosis  and  treatment of the condition for which surgery is to be performed;    (ii)  reservations  for  a hospital bed and for an operating room were  made prior to the performance of the tests;    (iii) the surgery actually takes  place  within  seven  days  of  such  presurgical tests; and    (iv) the patient is physically present at the hospital for the tests.    (3)  Every group policy delivered or issued for delivery in this state  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 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.    (4) (A) Every group policy delivered or issued for  delivery  in  this  state  which provides coverage for inpatient hospital care shall include  coverage for services  to  treat  an  emergency  condition  provided  in  hospital  facilities,  except  that  this provision shall not apply to a  policy which cover 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) In this paragraph, an "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 (i) 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 (ii) serious impairment to such person's bodily functions;  (iii) serious dysfunction of any bodily organ or part of such person; or  (iv) serious disfigurement of such person.    (5) (A) * (i) Every group or blanket policy delivered  or  issued  for  delivery  in  this  state  which  provides hospital, surgical or medical  coverage shall include coverage for maternity care, including  hospital,  surgical  or  medical  care to the same extent that coverage is provided  for illness or disease under the policy. Such maternity  care  coverage,  other than coverage for perinatal complications, shall include inpatienthospital  coverage for mother and newborn for at least forty-eight hours  after childbirth for any delivery other than a  caesarean  section,  and  for  at  least ninety-six hours after 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 required to pay for  duplicative routine  services  actually  provided  by  both  a  licensed  midwife and a physician.    * NB Effective until October 28, 2010    * (i)  Every  group or blanket policy delivered or issued for delivery  in this state which provides  hospital,  surgical  or  medical  coverage  shall  include coverage for maternity care, including hospital, surgical  or medical care to the same extent that coverage is provided for illness  or disease under the policy. Such maternity care  coverage,  other  than  coverage  for  perinatal complications, shall include inpatient hospital  coverage for mother and newborn for at  least  forty-eight  hours  after  childbirth  for  any delivery other than a caesarean section, and for at  least ninety-six hours after 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    (ii)  Maternity  care  coverage shall also include, at minimum, parent  education, assistance and training in breast or bottle feeding, and  the  performance of any necessary maternal and newborn clinical assessments.    (iii)  The  mother shall have the option to be discharged earlier than  the time periods established in item (i) of this subparagraph.  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 policy. The policy 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  policy  and  subject  to  the  provisions  of this subparagraph, and not  subject to deductibles, coinsurance or copayments.    (B) Coverage provided under this  paragraph  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.    (6)  (A)  Every  group  policy issued or delivered in this state 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:    (i)  subject  to the provisions of subparagraph (C) of this paragraph,  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(ii)  provided,  further  however,  that  subject to the provisions of  subparagraph (C) of this paragraph,  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   paragraph,  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    (iii)  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 subparagraph (C) of this paragraph.    (B)  Every  group  policy  issued  or  delivered  in  this state 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:    (i) subject to the provisions of subparagraph (C) of  this  paragraph,  in  no  case  shall such coverage exclude surgical or medical procedures  which would correct malformation, disease or  dysfunction  resulting  in  infertility; and    (ii)  provided,  further  however,  that  subject to the provisions of  subparagraph (C) of this paragraph,  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 paragraph,  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    (iii)  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 subparagraph (C) of this paragraph.    (C)   Coverage  of  diagnostic  and  treatment  procedures,  including  prescription drugs, used in the diagnosis and treatment  of  infertility  as  required  by  subparagraphs  (A)  and (B) of this paragraph shall be  provided in accordance with the provisions of this subparagraph.    (i) 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.    (ii)  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 subparagraph.    (iii)   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.    (iv) 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 subparagraph "period of  not less than twelve months" shall be  determined  by  calculating  suchtime  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.    (v)  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 clause (vi) of this subparagraph.    (vi) 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 subparagraph, 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.    (7)(A)  Every  group  or  blanket accident and health insurance policy  issued or issued for delivery  in  this  state  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, the commissioner 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'sself-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 by  a  certified  diabetes  nurse   educator,   certified   nutritionist,   certified  dietitian  or  registered dietitian upon the referral of a physician or other  licensed  health  care  provider legally authorized to prescribe under title eight  of the education law. Education provided by the certified diabetes nurse  educator, certified  nutritionist,  certified  dietitian  or  registered  dietitian  may  be  limited  to  group  settings  wherever  practicable.  Coverage for self-management education and education  relating  to  diet  shall also include home visits when medically necessary.    (B) 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 policy.    (C)  This  paragraph  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 employed in more  than one state unless such policy is issued under  the  New  York  state  health  insurance  plan  established  under  article eleven of the civil  service law or issued to or through a local government.    (8) (A) Every group or blanket policy delivered or issued for delivery  in this state which provides coverage for inpatient hospital care  shall  provide  such coverage for such period as is determined by the attending  physician in consultation with the patient to be  medically  appropriate  for  such  covered  person  undergoing  a  lymph  node  dissection  or a  lumpectomy for the treatment of breast cancer or a mastectomy covered by  the policy. 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  policy.  Written  notice  of  the availability of such coverage shall be  delivered to the policyholder prior to  inception  of  such  policy  and  annually thereafter.    (B)  An  insurer  providing  coverage  under  this  paragraph  and any  participating entity through which the insurer  offers  health  services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll  or  to  renew coverage under the terms of the policy or vary the  terms of the policy for the purpose  or  with  the  effect  of  avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person  to accept less than the minimum protections available under this  paragraph;    (iii) penalize in any way or reduce or limit  the  compensation  of  a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph;    (iv)  provide  incentives  (monetary  or  otherwise)  to a health care  practitioner  relating  to  the  services  provided  pursuant  to   this  paragraph  intended  to  induce  or  have  the  effect  of inducing such  practitioner  to  provide  care  to  a  covered  person  in   a   manner  inconsistent with this paragraph; or    (v)  restrict  coverage  for any portion of a period within a hospital  length of stay required under  this  paragraph  in  a  manner  which  is  inconsistent  with  the  coverage  provided for any preceding portion of  such stay.    (C) The prohibitions in subparagraph (B) of this paragraph shall be in  addition to the  provisions  of  sections  three  thousand  two  hundredthirty-one and three thousand two hundred thirty-two of this article and  nothing  in  this subparagraph shall be construed to suspend, supersede,  amend or otherwise modify such sections.    (9)(A)  Every policy which provides medical, major medical, or similar  comprehensive-type coverage must provide coverage for a  second  medical  opinion  by  an  appropriate  specialist, including but not limited to a  specialist affiliated with a specialty care center for the treatment  of  cancer,  in the event of a positive or negative diagnosis of cancer or a  recurrence of cancer or a recommendation of a course  of  treatment  for  cancer, subject to the following:    (i)  In  the  case  of  a  policy that requires, or provides financial  incentives for, the insured to receive covered services from health care  providers participating in a provider network  maintained  by  or  under  contract  with  the  insurer,  the  policy  shall include coverage for a  second medical opinion from a  non-participating  specialist,  including  but  not limited to a specialist affiliated with a specialty care center  for the treatment of cancer, when the  attending  physician  provides  a  written  referral  to  a  non-participating specialist, at no additional  cost to the insured  beyond  what  such  insured  would  have  paid  for  services  from a participating appropriate specialist. Provided, however  that nothing herein shall impair an insured's rights (if any) under  the  policy  to  obtain  the  second medical opinion from a non-participating  specialist without  a  written  referral,  subject  to  the  payment  of  additional  coinsurance  (if  any)  required  by the policy for services  provided by non-participating providers. The  insurer  shall  compensate  the  non-participating specialist at the usual, customary and reasonable  rate, or at a rate listed on a fee schedule filed and  approved  by  the  superintendent which provides a comparable level of reimbursement.    (ii)  In  the  case  of  a  policy  that  does  not  provide financial  incentives for, and does not require, the  insured  to  receive  covered  services  from health care providers participating in a provider network  maintained by or under contract  with  the  insurer,  the  policy  shall  include  coverage  for  a second medical opinion from a specialist at no  additional cost to the insured beyond what the insured would  have  paid  for comparable services covered under the policy.    (iii)   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  policy, and, where applicable, consistent with the provisions of clauses  (i) and (ii) of this subparagraph.    Nothing in this paragraph shall eliminate  or  diminish  an  insurer's  obligation  to comply with the provisions of section four thousand eight  hundred four of this chapter where applicable.  Written  notice  of  the  availability  of  such  coverage  shall be delivered to the policyholder  prior to the inception of such policy and annually thereafter.    (B) An  insurer  providing  coverage  under  this  paragraph  and  any  participating  entity  through  which  an insurer offers health services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll or to renew coverage under the terms of the policy  or  vary  the  terms  of  the  policy  for  the  purpose or with the effect of avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person to accept less than the minimum protections available under  this  paragraph;    (iii)  penalize  in  any  way or reduce or limit the compensation of a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph; or(iv) provide incentives (monetary  or  otherwise)  to  a  health  care  practitioner   relating  to  the  coverage  provided  pursuant  to  this  paragraph intended to  induce  or  have  the  effect  of  inducing  such  practitioner   to   provide  care  to  a  covered  person  in  a  manner  inconsistent with this paragraph.    (C) The prohibitions in subparagraph (B) of this paragraph shall be in  addition  to  the  provisions  of  sections  three  thousand two hundred  thirty-one and three thousand two hundred thirty-two of this article and  nothing in this subparagraph shall be construed to  suspend,  supersede,  amend or otherwise modify such sections.    (10)(A) Every group or blanket policy delivered or issued for delivery  in  this  state  which  provides  medical,  major  medical,  or  similar  comprehensive-type coverage shall provide  the  following  coverage  for  breast reconstruction surgery after a mastectomy:    (i) all stages of reconstruction of the breast on which the mastectomy  has been performed; and    (ii)  surgery  and  reconstruction  of  the  other breast to produce a  symmetrical appearance;  in the manner determined by the attending physician and the  patient  to  be  appropriate.  Such coverage may be subject to annual deductibles and  coinsurance  provisions  as   may   be   deemed   appropriate   by   the  superintendent  and  as  are consistent with those established for other  benefits within a given policy. Written notice of  the  availability  of  such  coverage shall be delivered to the policyholder prior to inception  of such policy and annually thereafter.    (B) An  insurer  providing  coverage  under  this  paragraph  and  any  participating  entity  through  which the insurer offers health services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll or to renew coverage under the terms of the policy  or  vary  the  terms  of  the  policy  for  the  purpose or with the effect of avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person to accept less than the minimum protections available under  this  paragraph;    (iii)  penalize  in  any  way or reduce or limit the compensation of a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph;    (iv) provide incentives (monetary  or  otherwise)  to  a  health  care  practitioner   relating  to  the  services  provided  pursuant  to  this  paragraph intended to  induce  or  have  the  effect  of  inducing  such  practitioner   to   provide  care  to  a  covered  person  in  a  manner  inconsistent with this paragraph; or    (v) restrict coverage for any portion of a period  within  a  hospital  length  of  stay  required  under  this  paragraph  in a manner which is  inconsistent with the coverage provided for  any  preceding  portion  of  such stay.    (C)  The  prohibitions  in  this paragraph shall be in addition to the  provisions of sections three thousand two hundred thirty-one  and  three  thousand  two  hundred  thirty-two  of  this article and nothing in this  paragraph shall be construed to suspend, supersede, amend  or  otherwise  modify such sections.    * (11)  Every  policy  which  provides coverage for prescription drugs  shall include coverage for the cost of enteral formulas for home use for  which a  physician  or  other  licensed  health  care  provider  legally  authorized  to  prescribe  under  title  eight  of the education law has  issued a written order. Such written order shall state that the  enteral  formula  is clearly medically necessary and has been proven effective asa disease-specific treatment regimen for those individuals  who  are  or  will  become  malnourished  or  suffer  from  disorders,  which  if left  untreated, cause chronic  physical  disability,  mental  retardation  or  death.  Specific  diseases  for  which enteral formulas have been proven  effective shall include, but are not limited to, inherited  diseases  of  amino-acid or organic acid metabolism; Crohn's Disease; gastroesophageal  reflux  with  failure  to thrive; disorders of gastrointestinal motility  such as chronic intestinal pseudo-obstruction; and multiple, severe food  allergies which if left untreated  will  cause  malnourishment,  chronic  physical disability, mental retardation or death. Enteral formulas which  are  medically  necessary and taken under written order from a physician  for the treatment of  specific  diseases  shall  be  distinguished  from  nutritional supplements taken electively. Coverage for certain inherited  diseases  of  amino  acid  and  organic  acid  metabolism  shall include  modified solid food products that  are  low  protein  or  which  contain  modified  protein  which  are medically necessary, and such coverage for  such modified solid food products for  any  calendar  year  or  for  any  continuous  period of twelve months for any insured individual shall not  exceed two thousand five hundred dollars.    * NB There are 2 par (11)'s    * (11)(A) Every policy which is a "managed care product" as defined in  subparagraph (D) of this paragraph that includes coverage for  physician  services  in  a physician's office, and every policy which is a "managed  care product" that provides major medical or similar  comprehensive-type  coverage  shall  include  coverage  for chiropractic care, as defined in  section six thousand  five  hundred  fifty-one  of  the  education  law,  provided  by  a  doctor of chiropractic licensed pursuant to article one  hundred  thirty-two  of  the  education  law,  in  connection  with  the  detection  or  correction  by  manual  or mechanical means of structural  imbalance, distortion or subluxation in the human body for  the  purpose  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. However, chiropractic care  and services may be subject to  reasonable  deductible,  co-payment  and  co-insurance  amounts,  reasonable fee or benefit limits, and reasonable  utilization review, provided that any such amounts, limits  and  review:  (a)  shall  not  function to direct treatment in a manner discriminative  against chiropractic care, and (b) individually and  collectively  shall  be  no  more  restrictive than those applicable under the same policy to  care  or  services  provided  by  other  health  professionals  in   the  diagnosis,  treatment  and management of the same or similar conditions,  injuries,  complaints,  disorders  or  ailments,   even   if   differing  nomenclature  is  used  to  describe  the  condition, injury, complaint,  disorder or ailment. Nothing herein  contained  shall  be  construed  as  impeding  or preventing either the provision or coverage of chiropractic  care and services by duly licensed doctors of chiropractic,  within  the  lawful scope of chiropractic practice, in hospital facilities on a staff  or employee basis.    (C)  Every  policy which includes coverage for physician services in a  physician's office, and every policy which  provides  major  medical  or  similar comprehensive-type coverage, other than a "managed care product"  as defined in subparagraph (D) of this paragraph, shall provide coverage  for  chiropractic  care, as defined in section six thousand five hundred  fifty-one of the education law, provided by  a  doctor  of  chiropractic  licensed  pursuant  to  article  one hundred thirty-two of the education  law, in connection  with  the  detection  or  correction  by  manual  or  mechanical  means  of structural imbalance, distortion or subluxation in  the human body for the purpose of removing nerve interference,  and  theeffects  thereof, where such interference is the result of or related to  distortion, misalignment or subluxation of or in the  vertebral  column.  However,  chiropractic  care  and  services may be subject to reasonable  deductible,  co-payment  and  co-insurance  amounts,  reasonable  fee or  benefit limits, and reasonable utilization  review,  provided  that  any  such  amounts,  limits  and  review:  (a)  shall  not function to direct  treatment in a manner discriminative against chiropractic care, and  (b)  individually  and  collectively  shall be no more restrictive that those  applicable under the same policy to care or services provided  by  other  health  professionals  in the diagnosis, treatment and management of the  same or similar conditions, injuries, complaints, disorders or ailments,  even if differing  nomenclature  is  used  to  describe  the  condition,  injury,  complaint,  disorder or ailment. Nothing herein contained shall  be construed as impeding or preventing either the provision or  coverage  of   chiropractic   care  and  services  by  duly  licensed  doctors  of  chiropractic, within the  lawful  scope  of  chiropractic  practice,  in  hospital facilities on a staff or employee basis.    (D)  For  purposes  of  this paragraph, a "managed care product" shall  mean a policy which requires that medical or other health care  services  covered  under  the  policy,  other  than  emergency  care  services, be  provided by, or pursuant to a referral from, a  primary  care  provider,  and  that services provided pursuant to such a referral be rendered by a  health  care  provider  participating  in  the  insurer's  managed  care  provider  network.  In  addition, a managed care product shall also mean  the in-network portion of a contract  which  requires  that  medical  or  other  health  care  services  covered  under  the  contract, other than  emergency care services, be provided by, or pursuant to a referral from,  a primary care provider, and that services provided pursuant to  such  a  referral  be  rendered  by  a  health care provider participating in the  insurer's managed care provider network, in order for the insured to  be  entitled to the maximum reimbursement under the contract.    (E)  The  coverage required by this paragraph shall not be abridged by  any regulation promulgated by the su	
	











































		
		
	

	
	
	

			

			
		

		

State Codes and Statutes

State Codes and Statutes

Statutes > New-york > Isc > Article-32 > 3221

§  3221.  Group  or  blanket  accident  and health insurance policies;  standard provisions. (a) No policy of  group  or  blanket  accident  and  health  insurance shall, except as provided in subsection (d) hereof, be  delivered or issued for delivery in this state  unless  it  contains  in  substance the following provisions or provisions which in the opinion of  the   superintendent   are   more  favorable  to  the  holders  of  such  certificates or not less favorable to the holders of  such  certificates  and   more  favorable  to  policyholders,  provided  however,  that  the  provisions set forth in paragraphs six and thirteen of  this  subsection  shall  not  be  applicable  to  any  such  policy  which  is issued to a  policyholder in accordance with subparagraph (E)  of  paragraph  one  of  subsection  (c) of section four thousand two hundred thirty-five of this  chapter:    (1) (A) No statement made  by  the  person  insured  shall  avoid  the  insurance  or  reduce  benefits thereunder unless contained in a written  instrument signed by the person insured.    (B) All statements contained in any such written instrument  shall  be  deemed representations and not warranties.    (2)  That  no agent has authority to change the policy or waive any of  its provisions and that no change in the policy shall  be  valid  unless  approved  by  an  officer of the insurer and evidenced by endorsement on  the policy, or by amendment to the policy signed by the policyholder and  the insurer.    (3) That all new employees or new members in the classes eligible  for  insurance must be added to such class for which they are eligible.    (4)  That  all  premiums due under the policy shall be remitted by the  employer or employers of the persons insured or by some other designated  person acting on behalf of the association  or  group  insured,  to  the  insurer  on or before the due date thereof, with such period of grace as  may be specified therein.    (5) The conditions under which the insurer may decline  to  renew  the  policy.    (6)  That  the insurer shall issue either to the employer or person in  whose name such policy is issued, for delivery to  each  member  of  the  insured  group,  a certificate setting forth in summary form a statement  of the essential features of the insurance coverage and in substance the  following provisions of this subsection.    (7) The ages,  to  which  the  insurance  provided  therein  shall  be  limited;  and  the ages, for which additional restrictions are placed on  benefits, and the additional restrictions placed on the benefits at such  ages.    (8) That written notice of claim must be given to the  insurer  within  twenty  days after the occurrence or commencement of any loss covered by  the policy. Failure to give notice within such time shall not invalidate  or reduce any claim if it shall be shown not  to  have  been  reasonably  possible  to  give  such notice and that notice was given as soon as was  reasonably possible.    * (9) That in the case of claim  for  loss  of  time  for  disability,  written  proof  of  such  loss  must  be furnished to the insurer within  thirty days after the commencement of the period for which  the  insurer  is liable, and that subsequent written proofs of the continuance of such  disability  must  be  furnished  to the insurer at such intervals as the  insurer may reasonably require, and that in the case of  claim  for  any  other  loss, written proof of such loss must be furnished to the insurer  within ninety days after the date of such loss. Failure to furnish  such  proof  within  such  time shall not invalidate or reduce any claim if it  shall be shown not to have been  reasonably  possible  to  furnish  suchproof  within  such  time,  provided such proof was furnished as soon as  reasonably possible.    * NB Effective until January 1, 2011    * (9)  That  in  the  case  of  claim for loss of time for disability,  written proof of such loss must  be  furnished  to  the  insurer  within  thirty  days  after the commencement of the period for which the insurer  is liable, and that subsequent written proofs of the continuance of such  disability must be furnished to the insurer at  such  intervals  as  the  insurer  may  reasonably  require, and that in the case of claim for any  other loss, written proof of such loss must be furnished to the  insurer  within  one  hundred twenty days after the date of such loss. Failure to  furnish such proof within such time shall not invalidate or  reduce  any  claim  if  it  shall  be  shown  not to have been reasonably possible to  furnish such proof within such time, provided such proof  was  furnished  as soon as reasonably possible.    * NB Effective January 1, 2011    (10)  That  the  insurer will furnish to the person making claim or to  the policyholder for delivery to such person such forms as  are  usually  furnished  by  it  for  filing  proof  of  loss.  If  such forms are not  furnished before the  expiration  of  fifteen  days  after  the  insurer  receives  notice  of  any claim under the policy, the person making such  claim shall be deemed to have complied  with  the  requirements  of  the  policy  as to proof of loss upon submitting within the time fixed in the  policy for filing proof of loss, written proof covering the  occurrence,  character and extent of the loss for which claim is made.    (11)  That the insurer shall have the right and opportunity to examine  the person of the individual for whom claim is made when and so often as  it may reasonably require during the pendency of claim under the  policy  and  also  the right and opportunity to make an autopsy in case of death  where it is not prohibited by law.    (12) That benefits payable under the policy other  than  benefits  for  loss  of  time will be payable not more than sixty days after receipt of  proof, and that, subject to due  proof  of  loss  all  accrued  benefits  payable  under  the  policy  for  loss  of  time  will  be paid not less  frequently than monthly during the continuance of the period  for  which  the  insurer  is  liable,  and  that any balance remaining unpaid at the  termination of such period will be paid immediately upon receipt of such  proof.    (13) That indemnity for loss of life of  the  insured  is  payable  in  accordance  with  subsection  (e)  of  section four thousand two hundred  thirty-five of this chapter; and  that  all  other  indemnities  of  the  policy  are  payable to the insured, except as may be otherwise provided  in accordance with  such  subsection;  and  that  if  a  beneficiary  is  designated,  the  consent  of  the beneficiary shall not be requisite to  change of beneficiary,  or  to  any  other  changes  in  the  policy  or  certificate, except as may be specifically provided by the policy.    (14) That no action at law or in equity shall be brought to recover on  the policy prior to the expiration of sixty days after proof of loss has  been filed in accordance with the requirements of the policy and that no  such action shall be brought after the expiration of two years following  the time such proof of loss is required by the policy.    (15)  Any policy and certificate, other than one issued in fulfillment  of the continuing care responsibilities of an operator of  a  continuing  care  retirement  community  in accordance with article forty-six of the  public health law, made available because of residence in  a  particular  facility,  housing development, or community shall contain the following  notice in twelve point type in bold face on the first page:"NOTICE - THIS POLICY OR CERTIFICATE DOES NOT MEET THE REQUIREMENTS OF  A CONTINUING CARE RETIREMENT CONTRACT.  AVAILABILITY  OF  THIS  COVERAGE  WILL  NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT  COMMUNITY."    * (16)  No policy delivered or issued for delivery in this state which  provides coverage for prescription drugs  and  for  which  cost-sharing,  deductibles  or  co-insurance  obligations are determined by category of  prescription   drugs   shall   impose   cost-sharing,   deductibles   or  co-insurance  obligations  for  any  prescription  drug that exceeds the  dollar amount of cost-sharing, deductibles or  co-insurance  obligations  for non-preferred brand drugs or its equivalent (or brand drugs if there  is no non-preferred brand drug category).    * NB Effective October 31, 2010    (b)  No  such policy shall be delivered or issued for delivery in this  state unless a schedule of the premium rates  pertaining  to  such  form  shall have been filed with the superintendent.    (c)  Any  portion of any such policy, which purports, by reason of the  circumstances under which a loss is incurred,  to  reduce  any  benefits  promised  thereunder  to  an amount less than that provided for the same  loss occurring under ordinary circumstances, shall be printed,  in  such  policy  and in each certificate issued thereunder, in bold face type and  with greater prominence than any other  portion  of  the  text  of  such  policy  or  certificate; and all other exceptions of the policy shall be  printed in the policy and in the certificate, with the  same  prominence  as  the  benefits  to  which they apply. If any such policy contains any  provision which affects the liability of the  insurer,  on  the  grounds  stated  in subparagraph (J) or (K) of paragraph two of subsection (d) of  section three thousand two hundred sixteen of this  article,  then  such  provision  shall  be contained in the policy and certificate in the form  set forth in such section.    (d) (1) The superintendent may approve any form of certificate  to  be  issued  under  a blanket accident and health insurance policy as defined  in section four thousand two hundred thirty-seven of this chapter, which  omits or modifies any of the provisions  hereinbefore  required,  if  he  deems  such  omission or modification suitable for the character of such  insurance and not unjust to the persons insured thereunder.    (2) The superintendent may approve any form of group insurance  policy  providing  disability  benefits to be issued pursuant to article nine of  the workers' compensation  law  which  omits  or  modifies  any  of  the  provisions  hereinbefore  required,  if such omission or modification is  not inconsistent with the provisions of such article nine and  he  deems  such  omission  or  modification  suitable  for  the  character  of such  insurance and not unjust to the persons insured thereunder.    (3) The superintendent may also approve any form  of  group  insurance  policy   to  be  issued  to  a  social  services  district  pursuant  to  subdivision two of section three hundred  sixty-seven-a  of  the  social  services law, which omits or modifies any of the provisions hereinbefore  required,  if  he  deems  such omission or modification suitable for the  character of such insurance.    (e)  (1)  A  group  policy  providing  hospital  or  surgical  expense  insurance  for  other  than  specific  diseases  or accident only, shall  provide that if the insurance on an employee or member insured under the  group policy ceases because of  termination  of  (I)  employment  or  of  membership  in  the  class  or  classes  eligible for coverage under the  policy or (II)  the  policy,  for  any  reason  whatsoever,  unless  the  policyholder  has  replaced the group policy with similar and continuous  coverage for the  same  group  whether  insured  or  self-insured,  such  employee  or  member  who has been insured under the group policy for atleast three months shall be entitled  to  have  issued  to  him  by  the  insurer  without  evidence  of insurability upon application made to the  insurer within forty-five days after such termination,  and  payment  of  the  quarterly,  or,  at  the  option  of the employee or member, a less  frequent premium applicable to the class of risk  to  which  the  person  belongs,  the  age of such person, and the form and amount of insurance,  an individual policy of insurance. The insurer may, at its option  elect  to  provide  the  insurance  coverage  under  a  group insurance policy,  delivered in this  state,  in  lieu  of  the  issuance  of  a  converted  individual policy of insurance. Such individual policy, or group policy,  as the case may be is hereafter referred to as the converted policy. The  benefits  provided under the converted policy shall be those required by  subsection (f), (g), (h) or (i) hereof, whichever is applicable and,  in  the  event  of  termination  of the converted group policy of insurance,  each insured thereunder shall have a right of conversion to a  converted  individual policy of insurance.    (2)  The  insurer  shall  not  be required to issue a converted policy  covering any person if such person is covered for  similar  benefits  by  another  hospital  or  surgical  or  medical expense insurance policy or  hospital or medical service subscriber contract or medical  practice  or  other  prepayment plan or by any other plan or program or such person is  eligible for similar benefits, whether or not  covered  therefor,  under  any arrangement of coverage for individuals in a group, other than under  the  converted  policy,  whether  on  an  insured  or uninsured basis or  similar benefits are provided for or available to such  person  pursuant  to any statute; and the benefits provided or available under any of such  sources  which  together  with the benefits provided under the converted  policy  would  result  in  overinsurance  or  duplication  of   benefits  according to standards on file with the superintendent.    (3)  The  converted  policy  shall,  at  the option of the employee or  member, provide identical coverage for the dependents of  such  employee  or  member  who  were covered under the group policy. Provided, however,  that if the employee or member chooses the option of dependent  coverage  then  dependents  acquired after the permitted time to convert stated in  paragraph one of this subsection shall be added to the converted  family  policy  in  accordance  with the provisions of subsection (c) of section  thirty-two  hundred  sixteen  of  this  article  and   any   regulations  promulgated  or  guidelines  issued by the superintendent. The converted  policy need not provide benefits in excess of those  provided  for  such  persons  under  the  group  policy from which conversion is made and may  contain any exclusion or  benefit  limitation  contained  in  the  group  policy or customarily used in individual policies. The effective date of  the  individual's  coverage under the converted policy shall be the date  of the termination of the individual's insurance under the group  policy  as to those persons covered under the group policy.    (4)  The  converted  policy shall not exclude a pre-existing condition  not excluded by the group policy  but  may  provide  that  any  benefits  payable  thereunder  may  be  reduced by the amount of any such benefits  payable under the group policy after the termination of the individual's  insurance thereunder, and during the first  year  of  such  individual's  coverage  under  the  converted  policy  the  benefits payable under the  policy may be reduced so that they are not in excess of those that would  have been payable had the individual's insurance under the group  policy  remained  in effect. The converted policy may provide for termination of  coverage thereunder on any person when he is  or  could  be  covered  by  Medicare (subchapter XVIII of the federal Social Security Act, 42 U.S.C.  §§ 1395 et seq) by reason of age.(5)  If  delivery  of  an  individual  converted  policy is to be made  outside this state, it may be on such form as the insurer  may  then  be  offering  for such conversion in the jurisdiction where such delivery is  to be made.    (6)  (A)  A  converted  policy  may  include  a  provision whereby the  insurer, during the first two years of an  individual's  coverage  under  the  policy,  may request information in advance of any premium due date  of such policy of any person covered thereunder  as  to  whether  he  is  covered  for similar benefits by another hospital or surgical or medical  expense insurance policy  or  hospital  or  medical  service  subscriber  contract  or  medical  practice or other prepayment plan or by any other  plan or program or similar benefits are provided for, or  available  to,  such person pursuant to any statute.    (B)  If  any  such person is so covered or such statutory benefits are  provided or available, and such person fails to furnish the insurer  the  details  of such coverage within thirty-one days after such request, the  benefits payable under the converted policy with respect to such  person  may  be  based  on the hospital or surgical or medical expenses actually  incurred after excluding  expenses  to  the  extent  of  the  amount  of  benefits provided or available therefor from any of the sources referred  to in subparagraph (A) hereof.    (7) The conversion provision shall also be available upon the death of  the  employee or member, to the surviving spouse with respect to such of  the spouse and children as are then covered by  the  group  policy,  and  shall  be  available  to a child solely with respect to himself upon his  attaining the limiting age of coverage  under  the  group  policy  while  covered  as  a dependent thereunder. It shall also be available upon the  divorce or annulment of the marriage of the employee or member,  to  the  former spouse of such employee or member.    (8)  (A) Each certificate holder shall be given written notice of such  conversion privilege and its duration  within  fifteen  days  before  or  after  the  date of termination of group coverage, provided that if such  notice be given more than fifteen days but less than ninety  days  after  the  date  of  termination  of  group coverage, the time allowed for the  exercise  of  such  privilege  of  conversion  shall  be  extended   for  forty-five  days  after the giving of such notice. If such notice be not  given within  ninety  days  after  the  date  of  termination  of  group  coverage, the time allowed for the exercise of such conversion privilege  shall expire at the end of such ninety days.    (B) Written notice by the policyholder given to the certificate holder  or  mailed  to  the  certificate holder's last known address, or written  notice by the insurer be sent by first class  mail  to  the  certificate  holder at the last address furnished to the insurer by the policyholder,  shall  be  deemed full compliance with the provisions of this subsection  for the giving of notice.    (C) A group contract issued by an insurer may contain a  provision  to  the  effect  that  notice  of such conversion privilege and its duration  shall be given by the  policyholder  to  each  certificate  holder  upon  termination of his group coverage.    (9)  This  subsection  shall  not  apply to a group policy issued to a  policyholder whose principal activities are located outside  this  state  by  any  life insurance company organized and operated without profit to  any private shareholder or individual, and operated exclusively for  the  purpose  of  aiding and strengthening charitable, religious, missionary,  education or philanthropic institutions, by issuing insurance  contracts  only  to or for the benefit of such institutions, to individuals engaged  in the services of such institutions and to  members  of  the  immediate  families of such individuals.(10)  (A)  This  subsection shall not apply to a group policy insuring  persons employed in an establishment  located  outside  this  state  and  their  dependents  issued  by  a  life  insurance company which has been  organized  for  the  purpose  of  establishing  a  non-profit  voluntary  employee  beneficiary association to provide life, sickness, accident or  other benefits to eligible employees or their beneficiaries, is operated  exclusively for said purposes and without profit, direct or indirect, to  any private shareholder or individual, and is duly  exempt  from  income  taxation, pursuant to the federal Internal Revenue Code.    (B)  Notwithstanding  the  provisions  of subparagraph (A) hereof, any  resident of this state and his dependents who are insured under a  group  policy  providing  hospital or surgical expense insurance for other than  specific diseases or accident only which is issued by a  life  insurance  company organized as aforementioned, shall be entitled to the conversion  privileges specified in this subsection.    (11)  In  addition  to the right of conversion herein, the employee or  member insured under the policy shall at his option, as  an  alternative  to  conversion,  be  entitled  to  have his coverage continued under the  group policy in accordance with the conditions and limitations contained  in subsection (m) of this section, and have issued at  the  end  of  the  period  of  continuation  an individual conversion policy subject to the  terms of this subsection. The effective date for the  conversion  policy  shall  be the day following the termination of insurance under the group  policy, or if there is a continuation of coverage, on the day  following  the  end  of  the period of continuation. Notwithstanding the foregoing,  the superintendent may require conversion or continuation  of  insurance  under  conditions  as  set  forth  in  a regulation for insureds under a  policy issued in accordance with subparagraph (E) of  paragraph  one  of  subsection  (c) of section four thousand two hundred thirty-five of this  chapter.    (f) Any employee or  member  who  upon  becoming  entitled  to  obtain  coverage  under  a converted policy has attained age sixty, and has been  insured for at least  two  years  under  the  group  policy  immediately  preceding  the  date  the  employee or member first became entitled to a  converted policy shall have the privilege of obtaining such policy for a  premium computed at a rate which in any policy year shall not exceed one  hundred  twenty  percent  of  a  net  level  premium  approved  by   the  superintendent  and  determined,  according  to  the attained age of the  insured at the time of conversion and the plan of reimbursement elected,  on the basis of current experience of licensed insurers  providing  such  coverage  and  of  reasonable assumptions as to morbidity, mortality and  interest. Such net level premium  may  be  changed  in  accordance  with  experience  and  with the approval of the superintendent at intervals of  not more frequently  than  five  years.  Notwithstanding  the  foregoing  provisions  of  this subsection, nothing herein shall be construed so as  to avoid the requirements of open enrollment and community rating as set  forth elsewhere in this chapter.    (g) The conversion privilege shall,  if  the  group  insurance  policy  insures  the  employee  or member for basic hospital or surgical expense  insurance, or if the group insurance  policy  insures  the  employee  or  member for comprehensive medical expense insurance, entitle the employee  or  member to obtain coverage under a converted policy providing, at his  option, coverage under any one of the  following  plans  on  an  expense  incurred basis:    (1) Plan I.    (A)  hospital  room  and  board expense benefits of one hundred thirty  dollars per day for a maximum duration of twenty-one days,(B) miscellaneous hospital expense benefits of a maximum amount of one  thousand three hundred dollars, and    (C)  surgical  operation  expense benefits according to a one thousand  four hundred dollar maximum benefit schedule, or    (2) Plan II.    (A) hospital room and board expense benefits  of  two  hundred  thirty  dollars per day for a maximum duration of thirty days,    (B) miscellaneous hospital expense benefits of a maximum amount of two  thousand three hundred dollars, and    (C)  surgical  operation  expense benefits according to a two thousand  four hundred dollar maximum benefit schedule, or    (3) Plan III.    (A) hospital room and board expense benefits of three  hundred  thirty  dollars a day for a maximum duration of seventy days,    (B)  miscellaneous  hospital  benefits  of  a  maximum amount of three  thousand three hundred dollars, and    (C) surgical operation expense benefits according to a three  thousand  five hundred dollar maximum benefit schedule.    (h)  The  conversion  privilege  shall,  if the group insurance policy  insures the employee or member for major medical expense  insurance,  or  if  the  group  insurance  policy  insures  the  employee  or member for  comprehensive medical expense insurance, entitle the employee or  member  to  obtain  coverage  under  a  converted policy providing major medical  coverage under one of the following plans or one at least  as  favorable  to the covered persons:    (1) A maximum conforming to subparagraph (A) or (B) hereof:    (A)  A maximum payment of two hundred thousand dollars for all covered  medical expenses combined during the covered person's lifetime, with  an  annual  restoration on each January first while coverage is in force, up  to five thousand dollars of  the  amount  counted  against  the  maximum  benefit and not previously restored.    (B)  A  maximum  payment  of  two  hundred  thousand  dollars for each  unrelated injury or sickness.    (2) Payment of benefits  up  to  eighty  percent  of  covered  medical  expenses  which  are  in  excess of the deductible, except that when the  combined deductible and other out-of-pocket covered medical expenses not  reimbursed by any other hospital, surgical or medical insurance  policy,  or  hospital  or  medical subscriber contract, or other prepayment plan,  exceed two thousand dollars, then payment of benefits shall  be  at  one  hundred percent of covered medical expenses.    (3)  (A) A deductible which is the greater of one thousand dollars and  the benefits deductible.    (B) The term "benefits deductible", as used herein, means the value of  any benefits provided on an expense incurred basis  which  are  provided  with  respect  to  covered  medical  expenses  by  any  other  hospital,  surgical, or medical insurance policy or  hospital  or  medical  service  subscriber contract or medical practice or other prepayment plan, or any  other  plan  or  program whether on an insured or uninsured basis, or in  accordance with the requirements of any  statute  and,  if  pursuant  to  subsection (i) hereof, the converted policy provides both basic hospital  or surgical coverage and major medical coverage, the value of such basic  benefits.    (C)  The insurer may require that the deductible be satisfied during a  period of not less than three months.    (4) (A) The benefit period  shall  be  each  calendar  year  when  the  maximum  payment  is  determined  by  subparagraph  (A) of paragraph one  hereof or twenty-four months when the maximum payment is  determined  by  subparagraph (B) of paragraph one hereof.(B)  For  the  purpose  of  determining the benefits payable, the term  "covered medical expenses", as used above,  is  defined  as  the  actual  expense  incurred, provided however, for hospital room and board charges  an insurer may limit the maximum major medical benefit  payable  to  the  lesser  of the hospital's most common semi-private room and board charge  or three hundred thirty dollars per day and, in  the  case  of  surgical  charges,  an insurer may limit the maximum major medical benefit payable  to the lesser of seventy-five percent of the prevailing  reasonable  and  customary  charges  or  the  benefit payable pursuant to a four thousand  five hundred dollar maximum benefit schedule.    (i) The conversion privilege shall,  if  the  group  insurance  policy  insures  the  employee  or member for basic hospital or surgical expense  insurance as well as major medical expense insurance, make available the  plans of benefits set forth in subsections (g) and (h)  hereof.  At  the  option  of the insurer, such plans of benefits may be provided under one  policy.    (j) No policy of group or blanket accident and health insurance  shall  be  issued  as  excess coverage for volunteer firemen over and above the  coverage provided for pursuant to the volunteer  firemen's  benefit  law  unless  such  excess  policy provides for each of the types of coverages  set forth in subdivision one of section five of  such  law.  Any  excess  policy  which  does not contain such provisions shall be construed as if  such coverages were embodied therein.    (k) (1) (A) Every group policy delivered or  issued  for  delivery  in  this  state  which  provides coverage for in-patient hospital care shall  provide coverage for home care to residents in this state,  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 home care coverage shall be included at the inception of  all  new  policies and, with respect to all other policies, added at any  anniversary date of the policy subject to evidence of insurability.    (B) Such coverage may be subject to an annual deductible of  not  more  than  fifty  dollars for each person covered under the policy and may be  subject to a coinsurance provision which provides for  coverage  of  not  less  than  seventy-five  percent  of  the  reasonable  charges for such  services.    (C) Home care means the care and treatment of a covered person who  is  under the care of a physician but only if hospitalization or confinement  in  a  nursing  facility  as  defined in subchapter XVIII of the federal  Social Security Act, 42 U.S.C. §§ 1395 et seq, would otherwise have been  required if home care was not provided, and the plan covering  the  home  health service is established and approved in writing by such physician.    (D)  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 and  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.    (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 under the contract if the covered person  had been hospitalized or confined  in  a  skilled  nursing  facility  asdefined  in  subchapter  XVIII  of  the  federal Social Security Act, 42  U.S.C. §§ 1395 et seq.    (E)  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 person covered under the contract; four hours  of home health aide service shall be considered as one home care visit.    (2) (A) Every insurer issuing a group policy delivered or  issued  for  delivery  in  this state which provides coverage for in-patient hospital  care shall include coverage for preadmission tests performed in hospital  facilities prior to scheduled surgery, 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.    (B)  Such  policy  shall  provide  benefits  for  tests  ordered  by a  physician which  are  performed  in  the  out-patient  facilities  of  a  hospital  as  a  planned  preliminary  to admission of the patient as an  in-patient for surgery in the same hospital, provided that:    (i) tests are necessary for and  consistent  with  the  diagnosis  and  treatment of the condition for which surgery is to be performed;    (ii)  reservations  for  a hospital bed and for an operating room were  made prior to the performance of the tests;    (iii) the surgery actually takes  place  within  seven  days  of  such  presurgical tests; and    (iv) the patient is physically present at the hospital for the tests.    (3)  Every group policy delivered or issued for delivery in this state  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 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.    (4) (A) Every group policy delivered or issued for  delivery  in  this  state  which provides coverage for inpatient hospital care shall include  coverage for services  to  treat  an  emergency  condition  provided  in  hospital  facilities,  except  that  this provision shall not apply to a  policy which cover 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) In this paragraph, an "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 (i) 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 (ii) serious impairment to such person's bodily functions;  (iii) serious dysfunction of any bodily organ or part of such person; or  (iv) serious disfigurement of such person.    (5) (A) * (i) Every group or blanket policy delivered  or  issued  for  delivery  in  this  state  which  provides hospital, surgical or medical  coverage shall include coverage for maternity care, including  hospital,  surgical  or  medical  care to the same extent that coverage is provided  for illness or disease under the policy. Such maternity  care  coverage,  other than coverage for perinatal complications, shall include inpatienthospital  coverage for mother and newborn for at least forty-eight hours  after childbirth for any delivery other than a  caesarean  section,  and  for  at  least ninety-six hours after 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 required to pay for  duplicative routine  services  actually  provided  by  both  a  licensed  midwife and a physician.    * NB Effective until October 28, 2010    * (i)  Every  group or blanket policy delivered or issued for delivery  in this state which provides  hospital,  surgical  or  medical  coverage  shall  include coverage for maternity care, including hospital, surgical  or medical care to the same extent that coverage is provided for illness  or disease under the policy. Such maternity care  coverage,  other  than  coverage  for  perinatal complications, shall include inpatient hospital  coverage for mother and newborn for at  least  forty-eight  hours  after  childbirth  for  any delivery other than a caesarean section, and for at  least ninety-six hours after 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    (ii)  Maternity  care  coverage shall also include, at minimum, parent  education, assistance and training in breast or bottle feeding, and  the  performance of any necessary maternal and newborn clinical assessments.    (iii)  The  mother shall have the option to be discharged earlier than  the time periods established in item (i) of this subparagraph.  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 policy. The policy 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  policy  and  subject  to  the  provisions  of this subparagraph, and not  subject to deductibles, coinsurance or copayments.    (B) Coverage provided under this  paragraph  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.    (6)  (A)  Every  group  policy issued or delivered in this state 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:    (i)  subject  to the provisions of subparagraph (C) of this paragraph,  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(ii)  provided,  further  however,  that  subject to the provisions of  subparagraph (C) of this paragraph,  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   paragraph,  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    (iii)  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 subparagraph (C) of this paragraph.    (B)  Every  group  policy  issued  or  delivered  in  this state 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:    (i) subject to the provisions of subparagraph (C) of  this  paragraph,  in  no  case  shall such coverage exclude surgical or medical procedures  which would correct malformation, disease or  dysfunction  resulting  in  infertility; and    (ii)  provided,  further  however,  that  subject to the provisions of  subparagraph (C) of this paragraph,  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 paragraph,  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    (iii)  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 subparagraph (C) of this paragraph.    (C)   Coverage  of  diagnostic  and  treatment  procedures,  including  prescription drugs, used in the diagnosis and treatment  of  infertility  as  required  by  subparagraphs  (A)  and (B) of this paragraph shall be  provided in accordance with the provisions of this subparagraph.    (i) 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.    (ii)  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 subparagraph.    (iii)   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.    (iv) 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 subparagraph "period of  not less than twelve months" shall be  determined  by  calculating  suchtime  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.    (v)  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 clause (vi) of this subparagraph.    (vi) 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 subparagraph, 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.    (7)(A)  Every  group  or  blanket accident and health insurance policy  issued or issued for delivery  in  this  state  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, the commissioner 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'sself-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 by  a  certified  diabetes  nurse   educator,   certified   nutritionist,   certified  dietitian  or  registered dietitian upon the referral of a physician or other  licensed  health  care  provider legally authorized to prescribe under title eight  of the education law. Education provided by the certified diabetes nurse  educator, certified  nutritionist,  certified  dietitian  or  registered  dietitian  may  be  limited  to  group  settings  wherever  practicable.  Coverage for self-management education and education  relating  to  diet  shall also include home visits when medically necessary.    (B) 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 policy.    (C)  This  paragraph  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 employed in more  than one state unless such policy is issued under  the  New  York  state  health  insurance  plan  established  under  article eleven of the civil  service law or issued to or through a local government.    (8) (A) Every group or blanket policy delivered or issued for delivery  in this state which provides coverage for inpatient hospital care  shall  provide  such coverage for such period as is determined by the attending  physician in consultation with the patient to be  medically  appropriate  for  such  covered  person  undergoing  a  lymph  node  dissection  or a  lumpectomy for the treatment of breast cancer or a mastectomy covered by  the policy. 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  policy.  Written  notice  of  the availability of such coverage shall be  delivered to the policyholder prior to  inception  of  such  policy  and  annually thereafter.    (B)  An  insurer  providing  coverage  under  this  paragraph  and any  participating entity through which the insurer  offers  health  services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll  or  to  renew coverage under the terms of the policy or vary the  terms of the policy for the purpose  or  with  the  effect  of  avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person  to accept less than the minimum protections available under this  paragraph;    (iii) penalize in any way or reduce or limit  the  compensation  of  a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph;    (iv)  provide  incentives  (monetary  or  otherwise)  to a health care  practitioner  relating  to  the  services  provided  pursuant  to   this  paragraph  intended  to  induce  or  have  the  effect  of inducing such  practitioner  to  provide  care  to  a  covered  person  in   a   manner  inconsistent with this paragraph; or    (v)  restrict  coverage  for any portion of a period within a hospital  length of stay required under  this  paragraph  in  a  manner  which  is  inconsistent  with  the  coverage  provided for any preceding portion of  such stay.    (C) The prohibitions in subparagraph (B) of this paragraph shall be in  addition to the  provisions  of  sections  three  thousand  two  hundredthirty-one and three thousand two hundred thirty-two of this article and  nothing  in  this subparagraph shall be construed to suspend, supersede,  amend or otherwise modify such sections.    (9)(A)  Every policy which provides medical, major medical, or similar  comprehensive-type coverage must provide coverage for a  second  medical  opinion  by  an  appropriate  specialist, including but not limited to a  specialist affiliated with a specialty care center for the treatment  of  cancer,  in the event of a positive or negative diagnosis of cancer or a  recurrence of cancer or a recommendation of a course  of  treatment  for  cancer, subject to the following:    (i)  In  the  case  of  a  policy that requires, or provides financial  incentives for, the insured to receive covered services from health care  providers participating in a provider network  maintained  by  or  under  contract  with  the  insurer,  the  policy  shall include coverage for a  second medical opinion from a  non-participating  specialist,  including  but  not limited to a specialist affiliated with a specialty care center  for the treatment of cancer, when the  attending  physician  provides  a  written  referral  to  a  non-participating specialist, at no additional  cost to the insured  beyond  what  such  insured  would  have  paid  for  services  from a participating appropriate specialist. Provided, however  that nothing herein shall impair an insured's rights (if any) under  the  policy  to  obtain  the  second medical opinion from a non-participating  specialist without  a  written  referral,  subject  to  the  payment  of  additional  coinsurance  (if  any)  required  by the policy for services  provided by non-participating providers. The  insurer  shall  compensate  the  non-participating specialist at the usual, customary and reasonable  rate, or at a rate listed on a fee schedule filed and  approved  by  the  superintendent which provides a comparable level of reimbursement.    (ii)  In  the  case  of  a  policy  that  does  not  provide financial  incentives for, and does not require, the  insured  to  receive  covered  services  from health care providers participating in a provider network  maintained by or under contract  with  the  insurer,  the  policy  shall  include  coverage  for  a second medical opinion from a specialist at no  additional cost to the insured beyond what the insured would  have  paid  for comparable services covered under the policy.    (iii)   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  policy, and, where applicable, consistent with the provisions of clauses  (i) and (ii) of this subparagraph.    Nothing in this paragraph shall eliminate  or  diminish  an  insurer's  obligation  to comply with the provisions of section four thousand eight  hundred four of this chapter where applicable.  Written  notice  of  the  availability  of  such  coverage  shall be delivered to the policyholder  prior to the inception of such policy and annually thereafter.    (B) An  insurer  providing  coverage  under  this  paragraph  and  any  participating  entity  through  which  an insurer offers health services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll or to renew coverage under the terms of the policy  or  vary  the  terms  of  the  policy  for  the  purpose or with the effect of avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person to accept less than the minimum protections available under  this  paragraph;    (iii)  penalize  in  any  way or reduce or limit the compensation of a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph; or(iv) provide incentives (monetary  or  otherwise)  to  a  health  care  practitioner   relating  to  the  coverage  provided  pursuant  to  this  paragraph intended to  induce  or  have  the  effect  of  inducing  such  practitioner   to   provide  care  to  a  covered  person  in  a  manner  inconsistent with this paragraph.    (C) The prohibitions in subparagraph (B) of this paragraph shall be in  addition  to  the  provisions  of  sections  three  thousand two hundred  thirty-one and three thousand two hundred thirty-two of this article and  nothing in this subparagraph shall be construed to  suspend,  supersede,  amend or otherwise modify such sections.    (10)(A) Every group or blanket policy delivered or issued for delivery  in  this  state  which  provides  medical,  major  medical,  or  similar  comprehensive-type coverage shall provide  the  following  coverage  for  breast reconstruction surgery after a mastectomy:    (i) all stages of reconstruction of the breast on which the mastectomy  has been performed; and    (ii)  surgery  and  reconstruction  of  the  other breast to produce a  symmetrical appearance;  in the manner determined by the attending physician and the  patient  to  be  appropriate.  Such coverage may be subject to annual deductibles and  coinsurance  provisions  as   may   be   deemed   appropriate   by   the  superintendent  and  as  are consistent with those established for other  benefits within a given policy. Written notice of  the  availability  of  such  coverage shall be delivered to the policyholder prior to inception  of such policy and annually thereafter.    (B) An  insurer  providing  coverage  under  this  paragraph  and  any  participating  entity  through  which the insurer offers health services  shall not:    (i) deny to a covered person eligibility, or continued eligibility, to  enroll or to renew coverage under the terms of the policy  or  vary  the  terms  of  the  policy  for  the  purpose or with the effect of avoiding  compliance with this paragraph;    (ii) provide incentives (monetary or otherwise) to encourage a covered  person to accept less than the minimum protections available under  this  paragraph;    (iii)  penalize  in  any  way or reduce or limit the compensation of a  health care practitioner for recommending or providing care to a covered  person in accordance with this paragraph;    (iv) provide incentives (monetary  or  otherwise)  to  a  health  care  practitioner   relating  to  the  services  provided  pursuant  to  this  paragraph intended to  induce  or  have  the  effect  of  inducing  such  practitioner   to   provide  care  to  a  covered  person  in  a  manner  inconsistent with this paragraph; or    (v) restrict coverage for any portion of a period  within  a  hospital  length  of  stay  required  under  this  paragraph  in a manner which is  inconsistent with the coverage provided for  any  preceding  portion  of  such stay.    (C)  The  prohibitions  in  this paragraph shall be in addition to the  provisions of sections three thousand two hundred thirty-one  and  three  thousand  two  hundred  thirty-two  of  this article and nothing in this  paragraph shall be construed to suspend, supersede, amend  or  otherwise  modify such sections.    * (11)  Every  policy  which  provides coverage for prescription drugs  shall include coverage for the cost of enteral formulas for home use for  which a  physician  or  other  licensed  health  care  provider  legally  authorized  to  prescribe  under  title  eight  of the education law has  issued a written order. Such written order shall state that the  enteral  formula  is clearly medically necessary and has been proven effective asa disease-specific treatment regimen for those individuals  who  are  or  will  become  malnourished  or  suffer  from  disorders,  which  if left  untreated, cause chronic  physical  disability,  mental  retardation  or  death.  Specific  diseases  for  which enteral formulas have been proven  effective shall include, but are not limited to, inherited  diseases  of  amino-acid or organic acid metabolism; Crohn's Disease; gastroesophageal  reflux  with  failure  to thrive; disorders of gastrointestinal motility  such as chronic intestinal pseudo-obstruction; and multiple, severe food  allergies which if left untreated  will  cause  malnourishment,  chronic  physical disability, mental retardation or death. Enteral formulas which  are  medically  necessary and taken under written order from a physician  for the treatment of  specific  diseases  shall  be  distinguished  from  nutritional supplements taken electively. Coverage for certain inherited  diseases  of  amino  acid  and  organic  acid  metabolism  shall include  modified solid food products that  are  low  protein  or  which  contain  modified  protein  which  are medically necessary, and such coverage for  such modified solid food products for  any  calendar  year  or  for  any  continuous  period of twelve months for any insured individual shall not  exceed two thousand five hundred dollars.    * NB There are 2 par (11)'s    * (11)(A) Every policy which is a "managed care product" as defined in  subparagraph (D) of this paragraph that includes coverage for  physician  services  in  a physician's office, and every policy which is a "managed  care product" that provides major medical or similar  comprehensive-type  coverage  shall  include  coverage  for chiropractic care, as defined in  section six thousand  five  hundred  fifty-one  of  the  education  law,  provided  by  a  doctor of chiropractic licensed pursuant to article one  hundred  thirty-two  of  the  education  law,  in  connection  with  the  detection  or  correction  by  manual  or mechanical means of structural  imbalance, distortion or subluxation in the human body for  the  purpose  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. However, chiropractic care  and services may be subject to  reasonable  deductible,  co-payment  and  co-insurance  amounts,  reasonable fee or benefit limits, and reasonable  utilization review, provided that any such amounts, limits  and  review:  (a)  shall  not  function to direct treatment in a manner discriminative  against chiropractic care, and (b) individually and  collectively  shall  be  no  more  restrictive than those applicable under the same policy to  care  or  services  provided  by  other  health  professionals  in   the  diagnosis,  treatment  and management of the same or similar conditions,  injuries,  complaints,  disorders  or  ailments,   even   if   differing  nomenclature  is  used  to  describe  the  condition, injury, complaint,  disorder or ailment. Nothing herein  contained  shall  be  construed  as  impeding  or preventing either the provision or coverage of chiropractic  care and services by duly licensed doctors of chiropractic,  within  the  lawful scope of chiropractic practice, in hospital facilities on a staff  or employee basis.    (C)  Every  policy which includes coverage for physician services in a  physician's office, and every policy which  provides  major  medical  or  similar comprehensive-type coverage, other than a "managed care product"  as defined in subparagraph (D) of this paragraph, shall provide coverage  for  chiropractic  care, as defined in section six thousand five hundred  fifty-one of the education law, provided by  a  doctor  of  chiropractic  licensed  pursuant  to  article  one hundred thirty-two of the education  law, in connection  with  the  detection  or  correction  by  manual  or  mechanical  means  of structural imbalance, distortion or subluxation in  the human body for the purpose of removing nerve interference,  and  theeffects  thereof, where such interference is the result of or related to  distortion, misalignment or subluxation of or in the  vertebral  column.  However,  chiropractic  care  and  services may be subject to reasonable  deductible,  co-payment  and  co-insurance  amounts,  reasonable  fee or  benefit limits, and reasonable utilization  review,  provided  that  any  such  amounts,  limits  and  review:  (a)  shall  not function to direct  treatment in a manner discriminative against chiropractic care, and  (b)  individually  and  collectively  shall be no more restrictive that those  applicable under the same policy to care or services provided  by  other  health  professionals  in the diagnosis, treatment and management of the  same or similar conditions, injuries, complaints, disorders or ailments,  even if differing  nomenclature  is  used  to  describe  the  condition,  injury,  complaint,  disorder or ailment. Nothing herein contained shall  be construed as impeding or preventing either the provision or  coverage  of   chiropractic   care  and  services  by  duly  licensed  doctors  of  chiropractic, within the  lawful  scope  of  chiropractic  practice,  in  hospital facilities on a staff or employee basis.    (D)  For  purposes  of  this paragraph, a "managed care product" shall  mean a policy which requires that medical or other health care  services  covered  under  the  policy,  other  than  emergency  care  services, be  provided by, or pursuant to a referral from, a  primary  care  provider,  and  that services provided pursuant to such a referral be rendered by a  health  care  provider  participating  in  the  insurer's  managed  care  provider  network.  In  addition, a managed care product shall also mean  the in-network portion of a contract  which  requires  that  medical  or  other  health  care  services  covered  under  the  contract, other than  emergency care services, be provided by, or pursuant to a referral from,  a primary care provider, and that services provided pursuant to  such  a  referral  be  rendered  by  a  health care provider participating in the  insurer's managed care provider network, in order for the insured to  be  entitled to the maximum reimbursement under the contract.    (E)  The  coverage required by this paragraph shall not be abridged by  any regulation promulgated by the su