May 19, 2015
State regulators recently modified the model contract language for plans in the individual and small group markets regarding “Additional Benefits, Equipment and Devices” which relates to the provision of essential health benefits. For plan years beginning on or after Jan. 1, 2014, non-grandfathered individual and small group plans must offer coverage for the ten categories of essential health benefits (EHB), known as the ‘EHB package’. Federal guidance suggests that coverage under an EHB package is generally limited to one external prosthetic device per lifetime. However, plans may rely on state’s benchmark plan (designated by each state) as a building block for the EHB package for plans sold in that state. New York is choosing to be more generous than the federal law requires by changing their model contract language. The language is changed to indicate that coverage of replacement prosthetics is required when it is not covered by warranty.
For standard plans on the NY exchange, this change must be included. For non-standard plans on the NY exchange and for plans offered outside of the exchange, this change is optional.
NYDFS Model Contract Section X »