N.Y. Comp. Codes R. & Regs. tit. 11 § 52.16

Current through Register Vol. 46, No. 18, May 1, 2024

Section 52.16 - Prohibited provisions and coverages

(a) No policy or certificate shall provide benefits for specified diseases, or for procedures or treatments unique to specified diseases, and no policy or certificate shall provide additional benefits for such specified diseases or procedures, unless the policy or certificate meets the standards set forth in section 52.15 or section 52.22 of this Part .

(b) No policy shall provide a return of premium or cash value benefit, except return of unearned premium upon termination or suspension of coverage, retroactive waiver of premium paid during disability, payment of dividends on participating policies, experience rating refunds, nonforfeiture values permitted for long-term care insurance, nursing home and home care insurance or nursing home insurance only, or a return of premium benefit upon death permitted for long-term care insurance, nursing home insurance only, home care insurance only, or nursing home and home care insurance. This prohibition applies to an accidental death benefit where the amount of the benefit equals the total premium paid to date of death.

(c) No policy shall limit or exclude coverage by type of illness, accident, treatment or medical condition, except as follows:

(1) preexisting conditions or diseases, as defined in section 52.2(u) of this Part or section 3232 or 4318 of the Insurance Law, except for congenital anomalies of a covered dependent child; subject to limitations set forth in subdivision (f) of this section, sections 52.17(a)(27)-(28), 52.18(a)(5) and 52.20 of this Part;

(2) mental or emotional disorders, alcoholism and drug addiction, except that coverage must be made available or provided pursuant to section 52.7 of this Part and sections 3221 and 4303 of the Insurance Law. Medicare supplement insurance issued pursuant to section 52.11 of this Part and Part 58 of this Title shall not include limitations or exclusions which are more restrictive than those of Medicare for this type of benefit;

(3) pregnancy, except to the extent coverage is required pursuant to sections 3216, 3221, 3232, 4303, and 4318 of the Insurance Law, and except for complications of pregnancy as defined in section 52.2(e) of this Part, other than for policies defined in section 52.8 of this Part;

(4) illness, accident, treatment or medical condition arising out of:

(i) war or act of war (whether declared or undeclared); participation in a felony, riot or insurrection; service in the Armed Forces or units auxiliary thereto;

(ii) suicide, attempted suicide or intentionally self-inflicted injury;

(iii) aviation, other than as a fare-paying passenger on a scheduled or charter flight operated by a scheduled airline; and

(iv) with respect to blanket insurance, interscholastic sports;

(5) cosmetic surgery, except that cosmetic surgery shall not include reconstructive surgery when such service is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part, and reconstructive surgery because of congenital disease or anomaly of a covered dependent child which has resulted in a functional defect. However, if the policy provides hospital, surgical or medical expense coverage, including a policy issued by a health maintenance organization, then coverage and determinations with respect to cosmetic surgery must be provided pursuant to Part 56 of this Title (Regulation 183);

(6) foot care, in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet; unless the policy is issued as Medicare supplement insurance pursuant to section 52.11 of this Part and Part 58 of this Title, in which case the policy shall not include limitations or exclusions more restrictive than those of Medicare for this type of benefit;

(7) care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion or subluxation in the human body for purposes of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column; unless the policy is issued as Medicare supplement insurance pursuant to section 52.11 of this Part and Part 58 of this Title, in which case the policy shall not include limitations or exclusions more restrictive than those of Medicare for this type of benefit;

(8) treatment provided in a government hospital; benefits provided under Medicare or other governmental program (except Medicaid), any State or Federal workers' compensation, employers' liability or occupational disease law; benefits to the extent provided for any loss or portion thereof for which mandatory automobile no-fault benefits are recovered or recoverable; services rendered and separately billed by employees of hospitals, laboratories or other institutions; services performed by a member of the covered person's immediate family; and services for which no charge is normally made;

(9) dental care or treatment, except for such care or treatment due to accidental injury to sound natural teeth within 12 months of the accident and except for dental care or treatment necessary due to congenital disease or anomaly;

(10) eyeglasses, hearing aids, and examination for the prescription or fitting thereof;

(11) rest cures, custodial care and transportation, unless the policy is issued as Medicare supplement insurance pursuant to section 52.11 of this Part and Part 58 of this Title, in which case the policy shall not include limitations or exclusions more restrictive than those of Medicare for this type of benefit; and

(12) coverage while the insured is outside the United States, its possessions or the countries of Canada and Mexico.

(d) No policy shall contain provisions establishing a probationary or similar period longer than the following:

(1) for all specified conditions: 30 days;

(2) for inception of pregnancy, except where otherwise specifically prescribed by statute: 30 days; and

(3) for accidents: none.

This subdivision shall not apply to benefits for dental, hearing or vision care.

(e) Except with respect to Medicare supplement insurance, as defined in section 52.11 of this Part and Part 58 of this Title, nothing contained in subdivisions (c) and (d) of this section shall preclude:

(1) the use of a nonduplication of coverage or coordination of benefit provision; or

(2) unless otherwise provided by law, waivers to exclude, limit or reduce coverage or benefits for specifically named or described disease, physical condition or extra-hazardous activity, as defined in section 52.2(i) of this Part, as an alternative to refusal to issue, renew or reinstate coverage.

Where waivers are required as a condition of issuance, renewal or reinstatement, signed acceptance by the insured is required unless on initial issuance the full text of the exclusion is contained either on the first page or specification page of the policy. Waivers to exclude, limit or reduce coverage or benefits for specifically named or described preexisting diseases or physical conditions shall not be used in Medicare supplement insurance.

(f) No group or blanket medical expense insurance policy insuring 300 or more persons, excluding dependents, shall contain a provision which excludes or limits coverage for preexisting conditions for any person who elects coverage during the first 30 days of eligibility. This provision shall not apply to blanket insurance where enrollment for the coverage is voluntary, to dental insurance, to insurance written under section 4235(c)(1)(H), (K), (L) and (M) of the Insurance Law or to the extent that insurance written under section 4235(c)(1)(B) and (D) of the Insurance Law insures employees of an employer with less than 300 employees.

(g) Except as provided for in subdivision (c) of this section, and coverages in effect after eligibility for Medicare, no policy shall set more than a single maximum benefit limit for any class of covered persons in each of the following categories of services provided by a hospital:

(1) hospital services other than room and board; and

(2) outpatient services.

(h) No community-rated policy issued by an article 43 corporation, other than a policy providing benefits through a health maintenance organization or its equivalent, and no individual policy, as defined in section 52.2(n) of this Part, shall provide benefits which duplicate benefits recoverable under mandatory automobile no-fault insurance policies unless such benefits are contained in a rider purchased at the option of the contract holder at an appropriate premium.

(i) The terms Medicare supplement, Medigap, Medicare Wrap-Around and words of similar import shall not be used unless the policy is issued or amended to comply with section 52.11 of this Part and Part 58 of this Title.

(j) The terms long term care and custodial care and words of similar import shall not be used in describing benefits unless the policy is issued or amended to comply with section 52.12 or 52.13 of this Part.

(k) Any application for a policy of limited benefits health insurance as defined in section 52.10 of this Part and any such policy, when offered to persons who are 65 years of age or older, must include the following notice:

(1) The application form shall incorporate immediately above the applicant's signature in bold print at least four points greater than the largest print used in the application, excluding the company name, logo and address, the following statement only:

The coverage applied for provides limited benefits health insurance only. This coverage does not meet the minimum requirements for Medicare supplement, long term care insurance, nursing home insurance only, home care insurance only, or nursing home and home care insurance in the state of New York. Purchase of this coverage may be unnecessary if you already have or intend to purchase Medicare supplement insurance or long term care insurance.

(2) The policy shall incorporate into the top quarter of the first page in bold print at least four points greater than the largest print used in the policy, excluding the company name, logo and address, the following statement only:

This policy provides limited benefits health insurance only. This coverage does not meet the minimum requirements for Medicare supplement, long-term care insurance, nursing home insurance only, home care insurance only, or nursing home and home care insurance in the state of New York. Purchase of this coverage may be unnecessary if you already have or intend to purchase Medicare supplement insurance or long term care insurance.

(l) No policy or certificate shall provide benefits for custodial care services unless that policy or certificate also provides insurance which meets the definition contained in section 52.11, 52.12 or 52.13 of this Part. For purposes of this section custodial care services means help in transferring, eating, dressing, bathing, toileting, and other such related activities.

(m)

(1) Pursuant to sections 4322(b-1) and 4326(d-1), no health maintenance organization or insurer shall issue a standardized individual enrollee direct payment contract issued pursuant to section 4321 or section 4322 of the Insurance Law, or a standardized health insurance contract for qualifying small employers and individuals issued pursuant to section 4326 of the Insurance Law, that provides coverage for drugs, procedures or supplies for the treatment of erectile dysfunction when provided to, or prescribed for use by, a person who is required to register as a sex offender pursuant to article 6-C of the Correction Law.

(2) Every notice of denial of coverage issued by a health maintenance organization or insurer pursuant to this subdivision shall advise the enrollee how to obtain additional information concerning the denial and the appeal process to challenge the denial. Use of a health maintenance organization's or insurer's existing grievance procedures shall be deemed sufficient to comply with the appeal requirements of this subdivision. Every such notice of denial shall also advise the enrollee that if the enrollee believes that he has been improperly placed on the registry of sex offenders maintained by the New York State Division of Criminal Justice Services, the enrollee should contact the division. The notice shall include the mailing address, phone number and web address of the division.

(3) Coverage of all drugs, procedures and supplies for the treatment of erectile dysfunction may be subject to prior determination of an enrollee's status under article 6-C of the Correction Law by a health maintenance organization or insurer for the purpose of implementing this subdivision.

(4) Nothing in this subdivision shall preclude a health maintenance organization or insurer from conducting utilization review on claims for coverage of drugs, procedures and supplies on behalf of an enrollee determined not to be a person required to register as a sex offender.

(5) Prior to obtaining access from the department of insurance to the registry information of sex offenders obtained from the New York State Division of Criminal Justice Services, a health maintenance organization or insurer shall execute a nondisclosure statement and authorization form as prescribed by the superintendent. The nondisclosure statement and authorization form shall be signed by an authorized officer of the health maintenance organization or insurer and shall contain the names of the persons in the employ of the health maintenance organization or insurer who are authorized to receive the information. By signing the form the authorized officer certifies that:

(i) the named employees of the health maintenance organization or insurer are authorized to receive information from the department of insurance regarding persons required to register as sex offenders;

(ii) the health maintenance organization or insurer has developed and implemented administrative, technical and physical safeguards to protect the security, confidentiality, and integrity of the information obtained pursuant to this subdivision, in accordance with Part 421 of this Title (Regulation 173), including but not limited to safeguards to ensure that such information will only be disclosed by the named employees to other persons in the employ of the health maintenance organization or insurer who are directly involved in approving or disapproving reimbursement or coverage for erectile dysfunction drugs, procedures and supplies and that no person receiving such information shall redisclose such information except to other persons in the employ of the health maintenance organization or insurer who are directly involved in approving or disapproving reimbursement or coverage for erectile dysfunction drugs, procedures and supplies; and

(iii) the health maintenance organization or insurer will promptly notify the department of insurance of any relevant changes of persons in the employ of the health maintenance organization or insurer who are authorized to receive such information.

(n)

(1) As used in this subdivision:

(i) Mental health professional means a person subject to the provisions of Education Law Article 131, 153, 154, or 163; or any other person designated as a mental health professional pursuant to law, rule, or regulation.

(ii) Conversion therapy:

(a) means any practice by a mental health professional that seeks to change an individual's sexual orientation or gender identity, including efforts to change behaviors, gender expressions, or to eliminate or reduce sexual or romantic attractions or feelings toward individuals of the same sex.

(b) Conversion therapy shall not include counseling or therapy for an individual who is seeking to undergo a gender transition or who is in the process of undergoing a gender transition, that provides acceptance, support, and understanding of an individual or the facilitation of an individual's coping, social support, and identity exploration and development, including sexual orientation-neutral interventions to prevent or address unlawful conduct or unsafe sexual practices, provided that the counseling or therapy does not seek to change sexual orientation or gender identity.

(2) No policy or certificate shall provide coverage for conversion therapy rendered by a mental health professional to an individual under the age of 18 years

(o)

(1) No policy delivered or issued for delivery in this State that provides hospital, surgical, or medical expense coverage shall limit or exclude coverage for abortions that are medically necessary. Coverage for in-network abortions that are medically necessary shall not be subject to copayments, or coinsurance, or annual deductibles, unless the policy is a high deductible health plan as defined in section 223(c)(2) of the Internal Revenue Code in which case coverage for medically necessary abortions may be subject to the plan's annual deductible.

(2) Notwithstanding any other provision of this Part, a group or blanket policy that provides hospital, surgical, or medical expense coverage delivered or issued for delivery in this State to a religious employer may exclude coverage for medically necessary abortions only if the insurer:

(i) obtains an annual certification from the group or blanket policyholder or contract holder that the policyholder or contract holder is a religious employer and that the religious employer requests a contract without coverage for medically necessary abortions;

(ii) issues a rider to each certificate holder (i.e., primary insured) at no premium to be charged to the certificate holder (i.e., primary insured) or religious employer for the rider, that provides coverage for medically necessary abortions subject to the same rules as would have been applied to the same category of treatment in the policy issued to the religious employer. The rider must clearly and conspicuously specify that the religious employer does not administer medically necessary abortion benefits, but that the insurer is issuing a rider for coverage of medically necessary abortions, and shall provide the insurer's contact information for questions; and

(iii) provides notice of the issuance of the policy and rider to the superintendent in a form and manner acceptable to the superintendent.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.16

Amended New York State Register July 20, 2016/Volume XXXVIII, Issue 29, eff. 9/18/2016

Amended New York State Register June 21, 2017 /Volume XXXIX, Issue 25, eff. 8/4/2017

Amended New York State Register October 31, 2018/Volume XL, Issue 44, eff. 10/31/2018