Supplement No. 1 to Insurance Circular Letter No. 4 (2022)

July 18, 2023

STATUTORY AND REGULATORY REFERENCES: N.Y. Insurance Law §§ 339, 3216, 3221, and 4303; 11 NYCRR Part 52 (Insurance Regulation 62)

I. Purpose

The purpose of this circular letter is to provide guidance to insurers authorized to write accident and health insurance in this state, article 43 corporations, health maintenance organizations (“HMOs”), student health plans certified pursuant to Insurance Law § 1124, municipal cooperative health benefit plans, and prepaid health services plans (collectively, “issuers”) regarding Chapter 739 of the Laws of 2022 and Chapter 78 of the Laws of 2023 (collectively, the “Chapters”), which enacted additional coverage requirements for preventive colorectal cancer screenings under large group comprehensive health insurance policies and contracts and notification requirements under certain comprehensive health insurance policies and contracts. This circular letter supplements Insurance Circular Letter No. 4 (2022) issued on March 30, 2022. This circular letter does not apply to Child Health Plus, Essential Plan, and Medicaid managed care coverage.

II. Coverage

Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) require issuers that deliver or issue for delivery an insurance policy or contract in New York providing hospital, surgical, or medical care coverage, except for a grandfathered health plan,¹ to provide coverage for preventive care and screenings at no cost-sharing when obtained from an in-network provider. This coverage requirement includes evidence-based care and screenings with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (“USPSTF”). The USPSTF recommendations include preventive screenings for colorectal cancer in adults beginning at the age of 45 and also extend to follow-up colonoscopies after an abnormal or positive non-invasive stool-based screening test or direct visualization screening test as recommended by the USPSTF and clarified in federal guidance issued on January 10, 2022 by the U.S. Department of Labor entitled “FAQS ABOUT AFFORDABLE CARE ACT IMPLEMENTATION PART 51, FAMILIES FIRST CORONAVIRUS RESPONSE ACT AND CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURITY ACT IMPLEMENTATION.” 11 NYCRR 52.76(a)(2) provides that a policy shall cover preventive care and screenings described in Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) upon any policy issuance or renewal that occurs six months or more after the date the recommendation or guideline described in Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) is issued.

The Chapters amended Insurance Law § 3221(l)(11-b) and added Insurance Law § 4303(uu) to require issuers that deliver or issue for delivery a large group comprehensive health insurance policy or contract in New York, including grandfathered health plans, to provide coverage for colorectal cancer preventive screenings in accordance with the American Cancer Society Guidelines for colorectal cancer screening of average risk individuals at no cost-sharing when obtained from an in-network provider. These coverage requirements include all additional colorectal cancer examinations and laboratory tests recommended in accordance with the American Cancer Society Guidelines for colorectal cancer screening of average risk individuals, including an initial colonoscopy or other medical test or procedure for colorectal cancer screening and a follow-up colonoscopy performed as a result of a positive result on a non-colonoscopy preventive screening test. Issuers must cover such colorectal cancer screenings, examinations, and laboratory tests recommended in accordance with the American Cancer Society Guidelines upon any policy or contract issuance or renewal that occurs six months or more after the date the guidelines are issued or updated. These requirements imposed by the Chapters apply to large group comprehensive health insurance policies and contracts issued or renewed on or after December 23, 2022.

Therefore, non-grandfathered large group comprehensive health insurance policies and contracts must provide coverage of colorectal cancer preventive screenings in accordance with both the USPSTF and American Cancer Society Guidelines, and grandfathered large group comprehensive health insurance policies and contracts must provide coverage of colorectal cancer preventive screenings in accordance with the American Cancer Society Guidelines.

III. Notification

Chapter 78 of the Laws of 2023 added a new Insurance Law § 339, which requires insurers authorized to write accident and health insurance in this state, article 43 corporations, and HMOs to notify, at least annually, insureds covered under individual, small group, and large group comprehensive health insurance policies or contracts of the colorectal cancer screenings that are covered under such policies or contracts. Insurance Law § 339 also requires these insurers to notify insureds covered under large group comprehensive health insurance policies or contracts at least annually of the most recently published American Cancer Society Guidelines for colorectal cancer screenings that are covered under such policies or contracts. The notification must be sent by United States postal mail unless the insured consents to an alternative method of notification, including electronic notification. The notice may be included with other disclosures that the insurer provides to insureds. The policy or contract itself may not be used to satisfy the notification requirement. The notification requirements apply to policies and contracts issued or renewed on or after December 23, 2022.

IV. Conclusion

Non-grandfathered large group comprehensive health insurance policies and contracts must provide coverage of colorectal cancer preventive screenings in accordance with both the USPSTF and American Cancer Society Guidelines, and grandfathered large group comprehensive health insurance policies and contracts must provide coverage of colorectal cancer preventive screenings in accordance with the American Cancer Society Guidelines. Note that non-grandfathered individual and small group comprehensive health insurance policies and contracts must provide coverage of colorectal cancer preventive screenings in accordance with the USPSTF recommendations. Insurers authorized to write accident and health insurance in this state, article 43 corporations, and HMOs must also comply with the applicable annual notification requirements imposed by Insurance Law § 339.

Please direct any questions regarding this circular letter by email to [email protected].

Very truly yours,

Lisette Johnson
Chief, Health Bureau