Skip to Content

State Mandated and Make Available Benefits for Comprehensive Commercial, HMO & Article 43 Health Insurance Contracts - As of September 1, 2015

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 for requirements for specific products. This information is also available in PDF format.

A. Mandated Benefits for Inclusion in Group Commercial, Individual Commercial, HMO & Article 43 Comprehensive Health Insurance Contracts

BENEFITGROUP COMMERCIALINDIVIDUAL COMMERCIALHMO/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)
See also: Circular Letter No. 1 (2002)
§3216(i)(9)
See also: Circular Letter No. 1 (2002)
§4303(a)(2)
See also: Circular Letter No. 1 (2002)
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)
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)
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

BENEFITGROUP COMMERCIALINDIVIDUAL COMMERCIALHMO/ARTICLE 43
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)
Supplemental home care §3221(l)(1) §3216(j)(2) N/A
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)


 

Link to DFS Portal

About DFS

Contact DFS

Reports & Publications

Licensing

Laws and Regs

Connect With DFS

DFS Facebook page

Follow NYDFS on Twitter