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Mandated and Make Available Benefits: Commercial, HMO & Article 43 Insurance Contracts

The following tables provide the citations to the Insurance Law for health insurance benefits. The benefit listing is current through March 1, 2012. Please note that each statute must be consulted to find if there are additional criteria for the benefit to be mandated for inclusion in a particular type of insurance contract. This information is also available in PDF format.

A. Mandated Benefits for Inclusion in Group Commercial, Blanket Commercial, Individual Commercial, Group HMO & Article 43 Insurance Contracts

BenefitGroup CommercialBlanket
Commercial
Individual CommercialGroup
HMO
Article 43
Home health care §3221(k)(1) N/A §3216(i)(6) §4303(a)(3) §4303(a)(3)
Preadmission testing §3221(k)(2) N/A §3216(i)(7) §4303(a)(1) §4303(a)(1)
Second surgical opinion §3221(k)(3) N/A §3216(i)(8) §4303(b) §4303(b)
Emergency medical services §3221(k)(4) See also: Circular Letter No. 1 (2002) N/A §3216(i)(9) See also: Circular Letter No. 1 (2002) §4303(a)(2) See also: Circular Letter No. 1 (2002) §4303(a)(2) See also: Circular Letter No. 1 (2002)
Maternity care §3221(k)(5) §3221(k)(5) §3216(i)(10) §4303(c) §4303(c)
Medical conditions leading to infertility §3221(k)(6) N/A §3216(i)(13) §4303(s) §4303(s)
Diabetic supplies, equipment, and self-management education §3221(k)(7) §3221(k)(7) §3216(i)(15-a) §4303(u) §4303(u)
Mastectomy care §3221(k)(8) §3221(k)(8) §3216(i)(18) §4303(v) §4303(v)
Second medical opinion for cancer diagnosis §3221(k)(9) §3221(k)(9) §3216(i)(19) §4303(w) §4303(w)
Post-mastectomy reconstruction §3221(k)(10) §3221(k)(10) §3216(i)(20) §4303(x) §4303(x)
Enteral Formulas §3221(k)(11) §3221(k)(11) §3216(i)(21) §4303(y) §4303(y)
Chiropractic care §3221(k)(11) §3221(k)(11) §3216(i)(21) §4303(y) §4303(y)
Experimental or investigational services recommended by an external appeal agent §3221(k)(12) §3221(k)(12) §3216(i)(22) §4303(z) §4303(z)
Chemical abuse and dependence (outpatient) §3221(l)(7) §3221(l)(7) N/A §4303(l) §4303(l)
Preventive and primary care §3221(l)(8) N/A §3216(i)(17) §4303(j) §4303(j)
Mammography screening §3221(l)(11) §3221(l)(11) §3216(i)(11) §4303(p) §4303(p)
Prostate cancer screening §3221(l)(11-a) §3221(l)(11-a) §3216(i)(11-a) §4303(z-1) §4303(z-1)
Cancer drugs §3221(l)(12) §3221(l)(12) §3216(i)(12) §4303(q) §4303(q)
Cervical cytology screening §3221(l)(14) §3221(l)(14) §3216(i)(15) §4303(t) §4303(t)
Pre-hospital emergency medical services §3221(l)(15) §3221(l)(15) §3216(i)(24) §4303(aa) §4303(aa)
End of life care §4805 §4805 §4805 Public Health Law §4406-e §4805
Infertility coverage §3321(k)(6) N/A N/A §4303(s) §4303(s)
Bone density measurements, testing , drugs, and devices §3221(k)(13) §3221(k)(13) N/A §4303(bb) §4303(bb)
Contraceptive drugs and devices §3221(l)(16) §3221(l)(16) N/A §4303 (cc) §4303 (cc)
Eating Disorders §3221(k)(14) §3221(k)(14) N/A §4303(dd) §4303(dd)
Mental, nervous or emotional disorders or ailments §3221(l)(5) §3221(l)(5) (school blanket only) N/A §4303(g) and (h) §4303(g) and (h)
Biologically based mental illness and serious emotional disturbances (large groups) §3221(l)(5) §3221(l)(5) (school blanket only) N/A §4303(g) and (h) §4303(g) and (h)
Autism Spectrum* [Statutes change effective 11/1/2012] §3221(l)(17) §3221(l)(17) 3216(i)(25) §4303(ee) §4303(ee)


B. Mandated Benefits for Inclusion in Individual Direct Pay HMO Contracts – §§ 4321 & 4322

The table below identifies the benefits and general information on the scope of the benefit in a standardized individual direct pay contract. However, unless Insurance Law §4322(b) expressly changes the requirements, Insurance Law §4303 should be consulted for the parameters of each benefit.

ServiceScope
Inpatient hospital services
  • Room & board
  • General nursing care
  • Special diets
  • Miscellaneous hospital services
Outpatient hospital services
  • Diagnostic & treatment services
  • X-rays
  • Laboratory tests
Physician services
  • Consultant & referral services, includes a second medical opinion for cancer diagnosis
  • Primary & preventive care
  • In-hospital medical services, includes mastectomy care
  • Surgical services, includes mastectomy reconstruction
  • Anesthetic services
  • Second surgical opinion
Preventive health services
  • Periodic physical exams, including eye and ear exams
  • Well child care
  • Immunizations
  • Mammography screening
  • Cervical cytology screening
Emergency services
  • Emergency medical services provided in a hospital
Diagnostic laboratory services 
Radiology services
  • Therapeutic
  • Diagnostic
Preadmission testing 
Home health care
  • Up to 200 visits per calendar year
Maternity care 
Chemotherapy services 
Hemodialysis services 
Outpatient physical therapy
  • Up to 90 visits per condition per calendar year
Hospice care
  • Up to 210 days
Skilled nursing facility care
  • When preceded by a hospital stay of at least three (3) days and further hospitalization would otherwise be necessary.
Diabetic treatment
  • Equipment
  • Supplies
  • Education
Inpatient mental health care
  • 30 days per calendar year (offset by chemical abuse treatment)
Outpatient mental health
  • Up to 30 non-emergency visits & 3 emergency visits per calendar year
Inpatient alcoholism & substance abuse
  • Up to 30 days per calendar year for detoxification (offset by inpatient mental health care)
Ambulance services 
Private duty nursing
  • Up to $5,000 per calendar year; $10,000 lifetime maximum
Durable medical equipment
  • Prosthetics
  • Orthotics
  • Durable medical equipment
  • Medical supplies
Inpatient physical rehabilitation services 
Blood & blood products 
Prescription drugs
  • Includes enteral formulas, cancer drugs, and contraceptive drugs and devices
  • Pharmacy
  • Mail order
Bone density measurements, testing , drugs, and devices 
Experimental or investigational services recommended by an external appeal agent 
End of life care* 
Eating Disorders 

* See Public Health Law §4406-e

C. Make Available Benefits for Inclusion in Group Commercial, Blanket Commercial, Individual Commercial, Group HMO & Article 43 Insurance Contracts

BenefitGroup
Commercial
Blanket
Commercial
Individual
Commercial
Group
HMO
Article 43
Nursing home care §3221(l)(2) N/A §3216(j)(1)(A) §4303(d) §4303(d) and (r)
Ambulatory care §3221(l)(3) N/A §3216(j)(1)(B) §4303(e) and (f) §4303(e) and (f)
Social worker §3221(l)(4) N/A N/A §4303(i) §4303(i)
Biologically based mental illness and serious emotional disturbances (small groups) §3221(l)(5) §3221(l)(5) (school blanket only) N/A §4303(g) and (h) §4303(g) and (h)
Inpatient treatment of alcoholism and substance abuse §3221(l)(6) §3221(l)(6) N/A §4303(k) §4303(k)
Registered nurse §3221(l)(9) N/A N/A §4303(m) §4303(m)
Hospice care §3221(l)(10) N/A N/A §4303(o) §4303(o)
Supplemental home care §3221(l)(1) N/A §3216(j)(2) N/A §4303(a)(3)(D)

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