State Mandated and Make Available Benefits for Comprehensive Commercial, HMO & Article 43 Health Insurance Contracts as of October 3, 2018
The following tables provide the citations to the Insurance Law for state mandates and make available benefits for comprehensive health insurance contracts. 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. Please note that additional benefits may be required pursuant to federal law. See the Product Checklists and Outlines available for requirements for specific products.
A. Mandated Benefits for Inclusion in Group Commercial, Individual Commercial, HMO & Article 43 Comprehensive Health Insurance Contracts
| BENEFIT | GROUP COMMERCIAL | INDIVIDUAL COMMERCIAL | HMO/ARTICLE 43 |
|---|---|---|---|
|
Home health care |
§3221(k)(1) |
§3216(i)(6) |
§4303(a)(3) |
|
Preadmission testing |
§3221(k)(2) |
§3216(i)(7) |
§4303(a)(1) |
|
Second surgical opinion |
§3221(k)(3) |
§3216(i)(8) |
§4303(b) |
|
Emergency services |
§3221(k)(4) |
§3216(i)(9) |
§4303(a)(2) |
|
Maternity care |
§3221(k)(5) |
§3216(i)(10) |
§4303(c) |
|
Medical conditions leading to infertility |
§3221(k)(6) |
§3216(i)(13) |
§4303(s) |
|
Infertility treatment |
§3221(k)(6) |
N/A |
§4303(s) |
|
Diabetic equipment, supplies, and self-management education |
§3221(k)(7) |
§3216(i)(15-a) |
§4303(u) |
|
Mastectomy care |
§3221(k)(8) |
§3216(i)(18) |
§4303(v) |
|
Second medical opinion for cancer diagnosis |
§3221(k)(9) |
§3216(i)(19) |
§4303(w) |
|
Post-mastectomy reconstruction |
§3221(k)(10) |
§3216(i)(20) |
§4303(x) |
|
Enteral formulas |
§3221(k)(11)* |
§3216(i)(21)* |
§4303(y)* |
|
Chiropractic care |
§3221(k)(11)* |
§3216(i)(21)* |
§4303(y)* |
|
Experimental or investigational services recommended by an external appeal agent |
§3221(k)(12) |
§3216(i)(22) |
§4303(z) |
|
Bone mineral density measurements or tests, drugs, and devices |
§3221(k)(13) |
N/A |
§4303(bb) |
|
Out-of-network dialysis |
§3221(k)(16) |
§3216(i)(27) |
§4303(gg) |
|
Eye drop refills |
§3221(k)(17) |
§3216(i)(28)* |
§4303(hh) |
|
Ostomy equipment and supplies |
§3221(k)(19) |
§3216(i)(30)* |
§4303(u-1) |
|
Inpatient mental health care services |
§3221(l)(5) |
N/A |
§4303(g) |
|
Outpatient mental health care services |
§3221(l)(5) |
N/A |
§4303(g) & (h) |
|
Inpatient substance use services |
§3221(l)(6) |
§3216(i)(30)* |
§4303(k) |
|
Outpatient substance use services |
§3221(l)(7) |
§3216(i)(31) |
§4303(l) |
|
Medication for the detoxification or maintenance treatment of a substance use disorder |
§3221(l)(7-a) |
N/A |
§4303(l-1) |
|
Preventive and primary health services |
§3221(l)(8) |
§3216(i)(17) |
§4303(j) |
|
Mammography screening |
§3221(l)(11) |
§3216(i)(11) |
§4303(p) |
|
Prostate cancer screening |
§3221(l)(11-a) |
§3216(i)(11-a) |
§4303(z-1) |
|
Off label cancer drugs |
§3221(l)(12) |
§3216(i)(12) |
§4303(q) |
|
Orally administered anticancer medications |
§3221(l)(12-a) |
§3216(i)(12-a) |
§4303(q-1) |
|
Cervical cytology screening |
§3221(l)(14) |
§3216(i)(15) |
§4303(t) |
|
Pre-hospital emergency medical services |
§3221(l)(15) |
§3216(i)(24) |
§4303(aa) |
|
Contraceptive drugs and devices |
§3221(l)(16) |
N/A |
§4303 (cc) |
|
Autism spectrum disorder treatment |
§3221(l)(17) |
§3216(i)(25) |
§4303(ee) |
|
Donor human breast milk |
§3221(l)(20)* |
§3216(i)(34)* |
§4303(oo) |
|
Essential health benefits |
§3221(h) |
§3216(l) |
§4328(b)(1)/§4303(ll) |
* Two benefits have a citation to the same paragraph or subsection number.
B. Make Available Benefits for Inclusion in Group Commercial, Individual Commercial, HMO & Article 43 Comprehensive Health Insurance Contracts
| BENEFIT | GROUP COMMERCIAL | INDIVIDUAL COMMERCIAL | HMO/ARTICLE |
|---|---|---|---|
|
Supplemental home care |
§3221(l)(1) |
§3216(j)(2) |
N/A |
|
Nursing home care |
§3221(l)(2) |
§3216(j)(1)(A) |
§4303(d) & (r) |
|
Ambulatory care |
§3221(l)(3) |
§3216(j)(1)(B) |
§4303(e) & (f) |
|
Social worker |
§3221(l)(4) |
N/A |
§4303(i) |
|
Registered nurse |
§3221(l)(9) |
N/A |
§4303(m) |
|
Hospice care |
§3221(l)(10) |
N/A |
§4303(o) |
|
Out-of-network benefits |
§3241(b) |
N/A |
§3241(b) |
|
Coverage of dependents through age 29 |
§4235(f)(1)(B) |
§3216(a)(4)(C) |
§4304(d)(1)(B) & §4305(c)(1)(B) |