Health Plans - New York

Summary of differences between Federal and State Regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. New York law includes the following provisions:

• If the plan provides for hospital or surgical expense, and employees lose coverage because of termination of employment or policy. The employees must be offered individual insurance, as long as the employee had been covered under the group policy for at least three months. The employee must apply for individual coverage within 45 days of the termination, and the insurance must be provided without requiring evidence of insurability. The insurer may provide group coverage instead of individual coverage. The conversion provision also applies to employees who die — the employee’s spouse and dependents may obtain a converted policy. (§3221(e))
• If the plan provides for inpatient hospital care, it must cover home care to residents in this state, with restrictions. (§3221(k)(1))
• If the plan provides for inpatient hospital care, it must cover preadmission tests performed in hospital facilities prior to scheduled surgery, including tests performed on an out-patient basis. (§3221(k)(2))
• If the plan provides for inpatient hospital care, it must cover a second surgical opinion by a qualified physician on the need for surgery. (§3221(k)(3))
• If the plan provides for inpatient hospital care, it must cover services to treat an emergency condition provided in hospital facilities. (§3221(k)(4))
• If the plan provides coverage for hospital, surgical, or medical care it must cover, for those between 21 and 44 years old, the diagnosis and treatment of correctable infertility medical conditions otherwise covered by the policy. This includes prescription drugs needed for diagnosis and treatment. This coverage may be limited to those covered under the group policy for at least 12 months. (§3221(k)(6))
• If the plan covers physician services in a physician's office, or provides major medical or similar comprehensive-type coverage, it must cover equipment and supplies for the treatment of diabetes. (§3221)(k)(7))
• If the plan provides coverage for medical, major medical, or similar comprehensive-type coverage must provide coverage for a second medical opinion by an appropriate specialist. (§3221 (k)(9)(A))
• If the plan covers prescription drugs, it must cover the cost of enteral formulas for home use prescribed by a licensed health care provider legally authorized to prescribe. (§3221 (k)(11))
• If the plan covers physician services in a physician's office, or major medical or similar comprehensive-type coverage (even if it is a managed care plan) it must cover chiropractic care. (§3221(k)(11)) Note: There are two paragraphs 11.
• Group health plans must include experimental or investigational health care services, clinical trials, or a prescribed pharmaceutical. (§3221(k)(12))
• If the plan provides major medical or similar comprehensive-type coverage, it must cover bone mineral density measurements or tests. (§3221(k)(13))
• If the plan provides medical, major medical or similar comprehensive-type coverage, it must cover services provided by a comprehensive care center for eating disorders. (§3221(k)(14))
• If the plan covers in-patient hospital care, it must offer optional coverage for nursing home care. (§3221(l)(2))
• If the plan covers in-patient hospital care, it must offer optional ambulatory care in hospital out-patient facilities. (§3221(l)(3)
• If the plan provides reimbursement for psychiatric or psychological services or for the diagnosis and treatment of mental, nervous or emotional disorders and ailments, however defined in the policy, by physicians, psychiatrists or psychologists, it must offer optional coverage for such services when performed by a licensed clinical social worker. (§3221(l)(4))
• If the plan covers inpatient hospital care, it must offer optional coverage for the diagnosis and treatment of mental, nervous or emotional disorders or ailments. (§3221(l)(5))
• If the plan covers inpatient hospital care, it must offer optional coverage for the diagnosis and treatment of chemical abuse and chemical dependence, including alcohol and substance abuse. (§3221(l)(6))
• If the plan covers inpatient hospital care, it must cover at least 60 outpatient visits in any calendar year for the diagnosis and treatment of chemical dependence of which up to 20 may be for family members. (§3221(l)(7))
• If the plan provides medical, major-medical or similar comprehensive-type coverage, if must cover preventive and primary care services for dependent children from birth to 19 years of age. (§3221(l)(8))
• The plan must offer optional coverage for the services of a duly licensed registered professional nurse. (§3221(l)(9))
• If the plan covers inpatient hospital care, it must offer optional coverage for hospice care. (§3221(l)(10))
• If the plan provides medical coverage that includes coverage for physician services in a physician's office or if the plan provides major medical or similar comprehensive-type coverage, it must cover, upon prescription, diagnostic screening for prostate cancer.  (§3221(l)(11-a))
• If the plan covers prescriptions, it must include drugs for certain types of cancer on the basis that the drugs have not been approved by the FDA. (§3221(l)(12))
• If the plan provides major medical or similar comprehensive-type coverage, it must cover prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service. (§3221(l)(15))
• If the plan covers prescriptions, it must cover contraceptive drugs or devices. (§3221(l)(16))
• If the plan covers hospital, surgical, or medical care, it must include coverage for diagnosis and treatment of autism spectrum disorder, including autism, Asperger syndrome, Rett's syndrome, or pervasive developmental disorder. (§3221(l)(17))
• Insurers must allow unmarried children through age 29 — regardless of financial dependence — to be covered under a parent's group health insurance policy. (§3221 (r)(1))
• Insurers must offer the option to continue coverage to unmarried children who have "aged off" of their parents' group health insurance policies. The "dependent children" may continue to be covered under their parents' group policy through age 29 as long as they are not eligible for employer sponsored health insurance coverage and are not covered by Medicare. Such children are not required to be financially dependent on their parents to elect this benefit. (§3221(r))
• Coverage must not be denied or cancelled by solely because the insured person has been exposed to diethylstilbestrol, commonly referred to as DES. (§3225)
• If the plan covers dependents who are full-time students, coverage must continue for 12 months from the last day of school attendance if the student takes a leave of absence from school due to illness. (§3237)
• If the plan provides for reimbursement of such services, the services may be provided by licensed audiologists, psychologists, occupational therapists, podiatrist, optometrist, dentists, speech-language pathologists, psychiatrists, or chiropractors. (§4235)
• If the plan covers dependents, it must cover newborns from the moment of birth, and adoptees from the time the insured takes custody. Coverage includes congenital defects and birth abnormalities including premature birth (if not already covered for the adoptee). (§4305)
• If the plan covers hospital, surgical or medical care and covers acute care services, it must cover advanced cancer for acute care services at an acute care facility. (§4805)
• For blanket accident and health plans, employees may include officers, manager, employees and retired employees of the employer and of subsidiary or affiliated corporations; the individual proprietors, partners, employees, and retired employees of affiliated individuals and firms controlled by the insured employer through stock ownership, contract or otherwise; and the individual proprietor or partners if the employer is an individual proprietorship or partnership. A07120 (§4273)
• Comprehensive group medical insurance policies shall include coverage for regular, non-emergency out-of-network dialysis, with proper medical authorization, notice and no increase in cost to insurer. (§3216; S 1803)
• Employers must report, on the NYS-45 form, whether dependent health insurance benefits are available to employees.
• The insurance regulations at Title 11 NYCRR, Regulation 171, require health plans to offer an additional Health New York benefit package which does not include prescription drugs and allows qualifying small employers and qualifying individuals to choose among the Health New York benefit packages. Qualifying small employers must elect to provide the same benefit package to all of their employees.
• Health insurance companies must provide coverage for diagnosis and treatment of autism spectrum disorders, though coverage may be subject to deductibles, co-pays, and coinsurance consistent with those imposed on other benefits. Previously, state law required only that insurance coverage not exclude the diagnosis and treatment of autism disorder. Chapter 596
• Screening and diagnostic imaging for the detection of breast cancer, including diagnostic mammograms, breast ultrasounds, or magnetic resonance imaging covered under the policy must not be subject to annual deductibles or coinsurance. This applies only with respect to participating providers in the insurer’s network, or to non-participating providers if the insurer does not have a participating provider in the in-network portion of its network with appropriate training and experience to meet the care needs of the insured. (§3221)Information on women’s health issues can be found under the topic “Women’s Health Rights.”
• Insurance companies must cover mammograms upon the recommendation of a physician 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 for individuals aged 35-39 inclusive; annual tests for individuals 40 and older, and annual screenings for individuals aged 35 to 39 inclusive, upon the recommendation of a physician, subject to the insurer's determination that the mammogram is medically necessary (§3221).
• Issuers who receive a claim from an insured of one gender or sex for a service that is typically or exclusively provided to an individual of another gender or sex should take reasonable steps, including requesting additional information, to determine whether the insured is eligible for the services prior to denying the claim. (§3224)
• Issuers may not deny medically necessary treatment otherwise covered by a health insurance policy or contract (“policy”) solely on the basis that the treatment is for gender dysphoria. (§§3221)

State

State contacts

New York Department of Insurance

State regulations

Laws of New York

ISC Insurance

Article 32 Insurance Contracts - Life, Accident and Health, Annuities

§3221 Group or blanket accident and health insurance policies; standard provisions

§3224 Standard claim forms; accident and health insurance

§3225 Eligibility for health insurance in cases of exposure to DES

§3237 Health insurance coverage for full-time students on medical leaves of absence

Article 42 Life Insurance Companies and Accident and Health Insurance Companies and Legal Services Insurance Companies

§4235 Group accident and health insurance

Article 43 Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations

§4305 Group contracts

§4326 for information regarding Health Savings Account (HSAs)

§4805 Access to end of life care

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)