2015 New York Laws
ISC - Insurance
Article 48 - (Insurance) MANAGED CARE HEALTH INSURANCE CONTRACTS
4801 - Application.

 4801. Application. The provisions of this article shall apply to all
  managed  care  products,  as  defined in subsection (c) of this section,
  which are delivered or issued for delivery in  this  state  by  insurers
  licensed  under  this  chapter;  provided,  however,  that  none  of the
  provisions of  this  article  shall  apply  to  any  health  maintenance
  organization lines of business of such insurers or to health maintenance
  organizations  certified  under  article forty-four of the public health
  law or licensed under article forty-three of  this  chapter,  which  are
  subject  to  the  provisions  of article forty-four of the public health
  law. For purposes of this article:
(a) an "insured" shall mean a person  covered  under  a  managed  care
  health insurance contract.
(b)  an  "insurer"  shall mean an insurance company subject to article
  thirty-two  of  this  chapter,  or  a  corporation  subject  to  article
  forty-three of this chapter.
(c)  a  "managed  care  health  insurance  contract"  or "managed care
  product" shall mean a contract which requires that all medical or  other
  health  care  services  covered under the contract, other than emergency
  care services, be provided  by,  or  pursuant  to  a  referral  from,  a
  designated  health  care  provider chosen by the insured (i.e. a primary
  care gatekeeper), and that services provided pursuant to such a referral
  be rendered by a health care provider  participating  in  the  insurer's
  managed  care  provider  network.  In  addition,  in  the case of (i) an
  individual health insurance contract, or (ii) a group  health  insurance
  contract   covering  no  more  than  three  hundred  lives,  imposing  a
  coinsurance obligation of more than twenty-five  percent  upon  services
  received  outside  of the insurer's provider network, and which has been
  sold to five or more groups, a managed care product shall  also  mean  a
  contract  which  requires that all medical or other health care services
  covered under the contract,  other  than  emergency  care  services,  be
  provided  by,  or  pursuant to a referral from, a designated health care
  provider chosen by the insured (i.e. a  primary  care  gatekeeper),  and
  that  services  provided  pursuant  to  such a referral be rendered by a
  health  care  provider  participating  in  the  insurer's  managed  care
  provider network, in order for the insured to be entitled to the maximum
  reimbursement under the contract.
(d)  "in-network  benefits"  shall  mean benefits covered and received
  under a managed care product from a health care  provider  participating
  in  the  insurer's  managed care provider network pursuant to a referral
  from the insured's participating primary care gatekeeper.