What Am I Covered For: State Health Insurance Mandates
State health insurance mandates are laws regulating the terms of coverage for insured health plans. Mandates can affect various parts of health insurance plans as follows:
Benefit mandates require health insurance plans to cover specific treatments, services or procedures. In some cases, however, benefit mandates require issuers to offer coverage for specific services or procedures to employers.
Provider mandates require health insurance plans to pay for services provided by specific health care professionals. Often, provider mandates are in the form of nondiscrimination mandates that require coverage only if the health plan already reimburses services within the scope of the health care professional’s practice.
Person mandates require health insurance plans to cover specific categories of people.
Additional mandates for health plans exist at the federal level. For instance, effective for plan years beginning on or after Jan. 1, 2014, the Affordable Care Act (ACA) requires non-grandfathered plans in the small group and individual markets to provide coverage for items and services designated as “essential health benefits.” Health plan sponsors and issuers should work with their advisors to determine how to comply with applicable federal and state mandates.
This Employment Law Summary contains a chart outlining New York’s benefit, provider and person mandates for insured group health plans issued in the state. Please keep in mind that the following chart does not address federal benefit mandates, such as the ACA’s mandates.
MANDATE & DESCRIPTION
Must make available and, if requested by the policyholder, provide coverage for ambulatory care in hospital outpatient facilities and physician offices. Ambulatory care generally includes services for diagnostic X-rays, laboratory and pathological examinations, radiation therapy, and services and medications used for non-experimental cancer chemotherapy and cancer hormone therapy. For care in hospital outpatient facilities, it also includes physical and occupational therapy.
Autism Spectrum Disorder:
Coverage for the screening, diagnosis and treatment of autism spectrum disorder. The treatment of autism spectrum disorder includes the following care and assistive communication devices prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist:
• Behavioral health treatment;
• Psychiatric and psychological care;
• Medical care provided by a licensed health care provider;
• Therapeutic care provided by social workers and speech, physical and occupational therapists, including therapeutic care which is deemed habilitative or nonrestorative, if the policy provides coverage for therapeutic care; and
• Pharmacy care, if the policy covers prescription drugs.
Bone Density Screenings:
Coverage for bone mineral density measurements or tests and, if a policy covers prescription drugs, drugs and devices approved by the federal Food and Drug Administration (FDA) or generic equivalents as approved substitutes.
Breast Cancer Surgery:
Coverage for a period of inpatient hospital care determined by the attending physician in consultation with the patient to be medically appropriate for a person undergoing a lymph node dissection or a lumpectomy for the treatment of breast cancer or a mastectomy covered by the policy.
Coverage for breast reconstruction surgery after a mastectomy or partial mastectomy, which must include all stages of reconstruction of the breast on which the mastectomy or partial mastectomy was performed, and surgery and reconstruction of the other breast to produce a symmetrical appearance.
Cervical Cytology Screenings:
Coverage for an annual cervical cytology screening for cervical cancer and its precursor states for women age 18 and older.
Coverage for chiropractic care 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, where the interference is the result of or related to distortion, misalignment or subluxation of the vertebral column.
Contraceptive Drugs and Devices:
If a policy covers prescription drugs, it must include coverage for contraceptive drugs and devices. A religious employer’s policy is not required to cover contraceptive methods that are contrary to the employer's religious beliefs; for these policies, subscribers have the option to purchase stand-alone contraceptive coverage.
Diabetes Equipment, Supplies and Education:
Coverage for equipment, supplies and self-management education for the treatment of diabetes.
Policies that only include coverage for in-network dialysis treatment cannot deny coverage of dialysis treatment provided by an out-of-network provider that is located outside of the issuer’s service area if there is proper medical authorization and notice to the insurer. This coverage may be limited to 10 out-of-network visits in a calendar year. This mandate does not require an insurer to reimburse the out-of-network provider at an amount greater than it would have paid for the same treatment within a network.
Emergency medical services:
Coverage for services to treat an emergency condition provided in hospital facilities without the need for any prior authorization and regardless of whether the health care provider furnishing such services is a participating provider.
Policies that cover prescription drugs must include coverage for the cost of enteral formulas for home use (whether administered orally or via tube feeding) when a physician or other licensed health care provider legally authorized to prescribe medications has issued a written order.
Coverage for certain inherited diseases of amino acid and organic acid metabolism must include modified solid food products that are low protein or that contain modified protein which are medically necessary: Coverage for modified solid food products is limited to $2,500 per covered person for any calendar year or continuous 12-month period.
Policies that cover prescription drugs must include coverage for the limited refilling of eye drop medication requiring a prescription prior to the last day of the approved dosage period.
Home health care:
Coverage for at least 40 home health care visits in any calendar year or continuous 12-month period for each covered person if hospitalization or confinement in a nursing facility would otherwise be required. This coverage must consist of:
• Part-time or intermittent home nursing care by or under the supervision of a registered professional nurse;
• Part-time or intermittent home health aide services that consist primarily of caring for the patient;
• Physical, occupational or speech therapy, if provided by the home health service or agency; and
• Medical supplies, drugs and medications prescribed by a physician, and laboratory services provided by or on behalf of a certified or licensed home health agency.
Must make available and, if requested by the policyholder, provide coverage for hospice care. This coverage must include at least 210 days of inpatient hospice care in a hospice or in a hospital and home care and outpatient services provided by the hospice, including drugs and medical supplies. It must also include five visits for bereavement counseling services, either before or after the insured's death, provided to the family of the terminally ill insured.
Cannot exclude coverage for hospital, surgical or medical care for the diagnosis and treatment of correctable medical conditions otherwise covered by the policy solely because the medical condition results in infertility. Coverage also cannot exclude:
• Surgical or medical procedures which would correct malformation, disease or dysfunction resulting in infertility; and
• Diagnostic tests and treatment procedures for infertility.
Infertility coverage must be provided for persons who are 21 through 44 years old. This coverage is NOT required to include the diagnosis and treatment of infertility in connection with certain procedures, including: (1) in vitro fertilization, gamete intrafallopian tube transfers or zygote intrafallopian tube transfers; (2) the reversal of elective sterilizations; or (3) medical or surgical services or procedures that are deemed to be experimental.
Policies that provide prescription drug coverage must cover FDA-approved drugs for use in the diagnosis and treatment of infertility.
Coverage for mammography screening for occult breast cancer as follows:
• Upon a physician’s recommendation, a mammogram (which may include breast tomosynthesis) at any age for covered persons having a prior history of breast cancer or who have a first degree relative with a prior history of breast cancer;
• A single baseline mammogram (which may include breast tomosynthesis) for covered persons age 35-39; and
• An annual mammogram (which may include breast tomosynthesis) for covered persons age 40 and older.
Screening and diagnostic imaging for the detection of breast cancer, including diagnostic mammograms, breast ultrasounds or magnetic resonance imaging, covered under the policy cannot be subject to annual deductibles or coinsurance.
Coverage for maternity care to the same extent that coverage is provided for illness or disease under the policy.
Maternity coverage, other than coverage for perinatal complications, must include inpatient hospital coverage for mother and newborn for at least 48 hours after a vaginal childbirth and for at least 96 hours after a caesarean section. The mother has the option to be discharged early and, in such cases, is entitled to at least one home care visit in addition to any other home health care coverage available under the policy. Maternity coverage must include the services of a licensed midwife whose practice meets certain requirements. It must also include parent education, assistance and training in breast or bottle-feeding, and the performance of any necessary maternal and newborn clinical assessments. The cost of renting or purchasing one breast pump per pregnancy in connection with childbirth is covered in full.
Mental health services:
Coverage for the diagnosis and treatment of mental, nervous or emotional disorders or ailments at least equal to the policy’s coverage for other health conditions.
The Mental Health Parity and Addiction Equity Act (MHPAEA) imposes federal parity requirements for employers with more than 50 employees that offer mental health or substance use disorder benefits in their group health plans. Depending on a plan’s design, the MHPAEA may require stricter parity requirements than state law mandates. Also, beginning in 2014, the ACA requires non-grandfathered health plans in the individual and small group markets to cover mental health and substance use disorder services and comply with the federal parity law.
Nursing home or skilled nursing facility care:
Must make available, and if requested by the policyholder, provide coverage for care in a nursing home or a skilled nursing facility.
Obstetric and gynecological care:
Policies that include coverage for obstetric/gynecological services cannot limit a female insured's direct access to primary and preventive obstetric/gynecologic services (including annual examinations, care resulting from such annual examinations and treatment of acute gynecologic conditions) from a qualified provider of her choice from within the plan or for any care related to a pregnancy. The qualified provider must discuss services and treatment plan with the insured’s primary care practitioner in accordance with the requirements of the issuer, follow the issuer’s policies and procedure and provide services pursuant to a treatment plan (if any) approved by the issuer.
Off-label cancer drug use:
Policies that cover prescription drugs approved by the FDA for the treatment of certain types of cancer cannot exclude coverage of any drug on the basis that it has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the FDA, provided the drug has been recognized for treatment of the specific type of cancer in certain medical reference compendia.
Oral cancer drugs:
Policies that cover prescription drugs and cancer chemotherapy treatment must provide coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells.
Coverage for equipment and supplies used for the treatment of ostomies, if prescribed by a physician or other licensed health care provider.
Coverage for preadmission tests performed in hospital facilities prior to scheduled surgery.
Pre-hospital emergency medical services:
Coverage for pre-hospital emergency medical services for the treatment of an emergency condition when the services are provided by an ambulance service that has received a certificate to operate pursuant to the New York public health law.
Prescription drugs – opioids:
Plans that provide coverage for prescription drugs subject to a copayment must charge a copayment for a limited initial prescription of an opioid drug prescribed for acute pain that is either:
• Proportional between the copayment for a 30-day supply and the amount of drugs the patient was prescribed; or
• Equivalent to the copayment for a full 30-day supply of the opioid drug, provided that no additional copayments may be charged for any additional prescriptions for the remainder of the 30-day supply.
Preventive and primary care for children
Coverage for the following preventive and primary care services for a covered child from the date of birth through age 19:
• An initial hospital check-up and well-child visits scheduled in accordance with the American Academy of Pediatrics;
• At each visit, services in accordance with the American Academy of Pediatrics, including a medical history, complete physical examination, developmental assessment, anticipatory guidance, and laboratory tests; and
• Necessary immunizations in accordance with the Advisory Committee on Immunization Practices.
Prostate cancer screenings:
Coverage for diagnostic screening for prostate cancer as follows:
• Standard diagnostic testing at any age for men having a prior history of prostate cancer; and
• An annual standard diagnostic examination for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors.
Second medical opinions for cancer diagnosis:
Coverage for a second medical opinion by an appropriate specialist 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.
Second surgical opinion:
Coverage for a second surgical opinion by a qualified physician on the need for surgery.
Substance use services – inpatient care:
Coverage for the diagnosis and treatment of substance use disorder, including detoxification and rehabilitation services. This coverage is also subject to federal parity requirements under the MHPAEA.
Substance use disorder – prescription drug treatment:
Coverage for immediate access, without prior authorization, to a five-day emergency supply of prescribed medications for the treatment of a substance use disorder, including a prescription drug to manage opioid withdrawal and/or stabilization and for opioid overdose reversal. If this coverage is subject to a copayment, the copayment must be either proportional between the copayment for a 30-day supply and the amount of prescribed drugs or equivalent to the copayment for a full 30-day supply, provided that no additional copayments may be charged for any additional prescriptions for the remainder of the 30-day supply.
Substance use disorder – outpatient services:
Outpatient coverage for the diagnosis and treatment of substance use disorder, including detoxification and rehabilitation services. This coverage is also subject to federal parity requirements under the MHPAEA. In addition, policies must provide up to 20 outpatient visits per year to an individual who identifies him or herself as a family member of a person suffering from substance use disorder and who seeks treatment as a family member who is otherwise covered by the applicable policy.
MANDATE & DESCRIPTION
If a policy covers any audiology service within the lawful scope of practice of a licensed audiologist, benefits must be provided for the service whether it is performed by a physician or a licensed audiologist. Nondiscrimination mandate.
If a policy covers any service within the scope of practice of a licensed chiropractor, benefits must be provided for the service when it is performed by a licensed chiropractor. Nondiscrimination mandate.
Choice of health care provider:
An issuer that requires or provides for designation by an insured of a participating primary care provider must permit the insured to designate any participating primary care provider who is available to accept the insured. In the case of a child, the issuer must permit the insured to designate a physician (allopathic or osteopathic) who specializes in pediatrics as the child’s primary care provider if such provider participates in the issuer’s network.
Clinical social worker:
If a policy provides reimbursement for mental health services by physicians, psychiatrists or psychologists, the issuer must make available and, if requested by the policyholder, provide the same coverage for these services when performed by a licensed clinical social worker within the lawful scope of his or her practice.
Comprehensive care centers for eating disorders:
Cannot deny benefits for services covered under a policy because they are provided by a comprehensive care center for eating disorders pursuant to the New York Public Health Law. Nondiscrimination mandate.
If a policy provides for reimbursement for any dental service within the lawful scope of practice of a licensed dentist, benefits must be provided for the service whether it is performed by a physician or a licensed dentist. Nondiscrimination mandate.
Under the maternity benefit mandate, coverage must be provided for the services of a licensed midwife who is practicing consistent with a collaborative relationship with a physician or hospital and who satisfies certain additional requirements.
If a policy covers any occupational therapy service within the lawful scope of practice of a licensed occupational therapist, benefits must be provided for the service whether it is performed by a physician or a licensed occupational therapist pursuant to prescription or referral by a physician. Nondiscrimination mandate.
If a policy covers any optometric service within the lawful scope of practice of a licensed optometrist, benefits must be provided for the service whether it is performed by a physician or a licensed optometrist. Nondiscrimination mandate.
If a policy covers any physical therapy service within the lawful scope of practice of a licensed physical therapist, benefits must be provided for the service whether it is performed by a physician or a licensed physical therapist pursuant to prescription or referral by a physician. Nondiscrimination mandate.
If a policy covers any service within the lawful scope of practice of a licensed podiatrist, benefits must be provided for the service whether it is performed by a physician or a licensed podiatrist. Nondiscrimination mandate.
If a policy covers psychiatric or psychological services or the diagnosis and treatment of mental, nervous or emotional disorders, benefits must be provided for the services, diagnosis or treatment whether performed by a physician, psychiatrist or a certified and registered psychologist when the services rendered are within the lawful scope of the provider’s practice. Nondiscrimination mandate.
Registered nurse first assistant:
If a policy covers non-physician surgical first assistant services when services are provided by a non-physician surgical first assistant, the policy must cover these services when they are performed by a registered nurse first assistant provided that: (1) the registered nurse first assistant is certified in operating room nursing, (2) the services are within the scope of practice of a non-physician surgical first assistant, and (3) the terms and conditions of the policy otherwise provide for the coverage of the services.
Registered professional nurse:
If a policy provides coverage for any service within the lawful scope of practice of a duly licensed registered professional nurse, an issuer must make available, and if requested by the contract holder, provide reimbursement for the service when it is performed by a duly licensed registered professional nurse. Nondiscrimination mandate.
Retail network pharmacies:
Policies that provide coverage for prescription drugs must permit insured individuals to fill a covered prescription that may be obtained at a network participating mail-order pharmacy (or other non-retail pharmacy) at a network participating non-mail order retail pharmacy. The retail pharmacy must agree to the same reimbursement amount, as well as the same applicable terms and conditions, that the issuer has established for the mail-order pharmacy.
Speech language pathologist:
If a policy provides coverage for any speech language pathology service within the lawful scope of practice of a duly licensed speech language pathologist, benefits must be provided for the service whether it is provided by a physician or by a licensed speech language pathologist. Nondiscrimination mandate.
Cannot exclude from coverage a service that is otherwise covered under the policy because the service is delivered via telehealth. Nondiscrimination mandate.
MANDATE & DESCRIPTION
Must offer continuation coverage to employees, spouses and dependent children who would otherwise lose coverage due to a qualifying event. Qualifying events include: the employee’s termination of employment or membership in the class or classes eligible for coverage; the employee’s death; the divorce or legal separation of the employee from his or her spouse; the employee becoming entitled to benefits under Medicare; or a dependent child’s loss of eligibility under the terms of the plan. The maximum continuation period is 36 months. State continuation coverage does not apply to individuals who are eligible to continue coverage under federal COBRA for 36 months.
Dependent coverage – age 26:
Policies that provide coverage for children must provide this coverage to a child until age 26, without regard to marital status, financial dependence, residency with the employee or member, student status or employment.
Dependent coverage – age 30:
Issuers must make available and, if requested by the policyholder, extend coverage under a policy to an eligible unmarried child through age 29 without regard to financial dependence. To be eligible for this coverage, the unmarried child: (1) must live, work or reside in New York or the insurer’s service area; and (2) cannot be eligible for coverage under any employer health benefit plan as an employee or member.
Dependent coverage - Medical leave of absence:
Policies that provide coverage for dependent children past age 26 who are full-time students must continue the coverage of a dependent student who takes a leave of absence from school due to illness. This coverage must continue for a period of 12 months from the last day of attendance in school, or if earlier, until the age coverage would otherwise terminate under the policy.
Policies that provide dependent coverage must provide coverage for unmarried dependent children, regardless of age, who are incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation or physical handicap and who are chiefly dependent upon the employee or member for support and maintenance. To qualify for this extended coverage, a child must have become disabled prior to attaining the policy’s limiting age.
Policies providing family coverage must provide that coverage of newborns is effective from the moment of birth for injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, including premature birth. This mandate also applies to newborn infants adopted by the insured if the insured takes physical custody of the infant upon such infant's release from the hospital and certain procedure requirements are satisfied.
*While many of the mandates described in the above chart are applicable to managed care plans, such as health maintenance organizations (HMOs), managed care plans may be subject to additional requirements under New York statutes and regulations that are not specifically addressed in the above chart. In addition, the chart focuses on mandates applicable to health insurance plans sponsored by private employers, and does not address mandates specifically applicable to the health benefits provided by government employers.
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