2012 New York Consolidated Laws
ISC - Insurance
Article 43 - (4301 - 4327) NON-PROFIT MEDICAL AND DENTAL INDEMNITY, OR HEALTH AND HOSPITAL SERVICE CORPORATIONS
4321 - Standardization of individual enrollee direct payment contracts offered by health maintenance organizations.

 
    §   4321.   Standardization  of  individual  enrollee  direct  payment
  contracts offered by health maintenance organizations. (a) On and  after
  January  first,  nineteen  hundred  ninety-six,  all  health maintenance
  organizations issued a certificate of authority under article forty-four
  of the public health law or licensed under this article  shall  offer  a
  standardized individual enrollee contract on an open enrollment basis as
  prescribed  by section forty-three hundred seventeen of this article and
  section forty-four hundred six of the public health law, and regulations
  promulgated thereunder, provided, however, that such requirements  shall
  not  apply  to  a  health  maintenance  organization exclusively serving
  individuals enrolled pursuant to title eleven of  article  five  of  the
  social  services  law,  title  eleven-D  of  article  five of the social
  services law, title one-A of article twenty-five of  the  public  health
  law  or  title eighteen of the federal Social Security Act, and, further
  provided,  that  such  health   maintenance   organization   shall   not
  discontinue  a  contract  for an individual receiving comprehensive-type
  coverage in effect prior to January first,  two  thousand  four  who  is
  ineligible to purchase policies offered after such date pursuant to this
  section  or  section  four  thousand  three  hundred  twenty-two of this
  article due to the provision of 42 U.S.C.  1395ss  in  effect  prior  to
  January  first,  two thousand four. On and after January first, nineteen
  hundred ninety-six, the  enrollee  contracts  issued  pursuant  to  this
  section  and  section  four  thousand  three  hundred twenty-two of this
  article shall be  the  only  contracts  offered  by  health  maintenance
  organizations  to individuals. The enrollee contracts issued by a health
  maintenance organization under this section and  section  four  thousand
  three  hundred  twenty-two  of  this  article  shall  also  be  the only
  contracts issued by health maintenance  organizations  for  purposes  of
  conversion  pursuant  to  sections  four thousand three hundred four and
  four thousand three hundred five of this article.  However,  nothing  in
  this section shall be deemed to require health maintenance organizations
  to terminate individual direct payment contracts issued prior to January
  first,   nineteen  hundred  ninety-six  or  prevent  health  maintenance
  organizations  from  terminating  individual  direct  payment  contracts
  issued prior to January first, nineteen hundred ninety-six.
    (b) The standardized individual enrollee direct payment contract shall
  provide coverage for all health services which an enrolled population in
  a   health  maintenance  organization  might  require  in  order  to  be
  maintained in good health, rendered without limitation as  to  time  and
  cost,  except  to the extent permitted by this chapter; provided however
  that no  individual  enrollee  and  no  family  unit  enrolled  in  such
  organization  shall  incur  out-of-pocket  costs  in  excess  of fifteen
  hundred  dollars  and  three  thousand  dollars,  respectively,  in  any
  calendar  year.  Such covered services shall be identical to the in-plan
  covered benefits of the standardized individual direct payment  enrollee
  contract  described in section four thousand three hundred twenty-two of
  this article, except as otherwise provided in subsections (c),  (d)  and
  (e) of this section.
    (c)  The health maintenance organization shall impose a fifteen dollar
  copayment on all visits to  a  physician  or  other  provider  with  the
  exception of visits for pre-natal and post-natal care, well child visits
  provided  pursuant  to  paragraph  two of subsection (j) of section four
  thousand three hundred three of this article, preventive health services
  provided pursuant to subparagraph (F) of paragraph  four  of  subsection
  (b)  of  section four thousand three hundred twenty-two of this article,
  or items or services for  bone  mineral  density  provided  pursuant  to
  subparagraph  (D)  of  paragraph twenty-six of subsection (b) of section
  four thousand three hundred twenty-two of  this  article  for  which  no

  copayment  shall  apply. A copayment of fifteen dollars shall be imposed
  on equipment, supplies and self-management education for  the  treatment
  of  diabetes.  A  fifty  dollar  copayment shall be imposed on emergency
  services  rendered  in  the  emergency room of a hospital; however, this
  copayment  must  be  waived  if  hospital  admission  results.  Surgical
  services shall be subject to a copayment of the lesser of twenty percent
  of  the  cost  of such services or two hundred dollars per occurrence. A
  five hundred dollar copayment shall be  imposed  on  inpatient  hospital
  services   per  continuous  hospital  confinement.  Ambulatory  surgical
  services shall be subject to a facility copayment charge of seventy-five
  dollars. Coinsurance of ten  percent  shall  apply  to  visits  for  the
  diagnosis  and  treatment  of  mental, nervous or emotional disorders or
  ailments.
    (d) The provisions of each health  maintenance  organization  contract
  describing  administrative procedures and other provisions not affecting
  the scope of, or conditions for obtaining, covered  benefits,  such  as,
  but  not  limited  to, eligibility and termination provisions, may be of
  the type generally used by the health maintenance organization, as  long
  as the superintendent determines that the terms and description of those
  administrative  and  other  provisions are unlikely to affect consumers'
  determinations of which health maintenance  organization's  contract  to
  purchase  and  are  not  contrary to law. Each contract may also include
  limitations and conditions on coverage of  benefits  described  in  this
  section  provided  the  superintendent  determines  the  limitations and
  conditions on coverage were  commonly  included  in  health  maintenance
  organization  and/or health insurance products covering individuals on a
  direct  payment  basis  prior  to  January   first,   nineteen   hundred
  ninety-six, and are not contrary to law.
    (e)  The  superintendent shall be authorized to modify, by regulation,
  the copayments, deductibles and coinsurance amounts  described  in  this
  section,  if the superintendent determines such amendments are necessary
  to moderate potential premiums. On  or  after  January  first,  nineteen
  hundred   ninety-eight,   the  superintendent  shall  be  authorized  to
  establish one or more additional standardized individual enrollee direct
  payment contracts if the superintendent determines, after  one  or  more
  public  hearings, additional contracts with different levels of benefits
  are necessary to meet the needs of the public.
    (f) No contract issued  pursuant  to  this  section  or  section  four
  thousand three hundred twenty-two of this article shall exclude coverage
  of  a health care service, as defined in paragraph two of subsection (e)
  of section four thousand nine  hundred  of  this  chapter,  rendered  or
  proposed  to be rendered to an insured on the basis that such service is
  experimental or investigational, is rendered as part of a clinical trial
  as defined in subsection (b-2) of section  forty-nine  hundred  of  this
  chapter,   or   a   prescribed   pharmaceutical  product  referenced  in
  subparagraph  (B)  of  paragraph  two  of  subsection  (e)  of   section
  forty-nine hundred of this chapter provided that coverage of the patient
  costs  of  such  service  has  been  recommended  for  the insured by an
  external appeal agent upon an appeal conducted pursuant to  subparagraph
  (B)  of  paragraph  four of subsection (b) of section four thousand nine
  hundred fourteen of this chapter.  The  determination  of  the  external
  appeal  agent  shall  be  binding  on  the parties. For purposes of this
  subsection, patient costs shall have the same meaning as such  term  has
  for  purposes of subparagraph (B) of paragraph four of subsection (b) of
  section four thousand nine hundred fourteen of this  chapter;  provided,
  however,  that  coverage for the services required under this subsection
  shall  be  provided  subject  to  the  terms  and  conditions  generally
  applicable to other benefits provided under the policy.