NY Civ Serv L § 162 (2021)
2021 New York Laws CVS - Civil Service Article 11 - Health Benefits for State and Retired State Employees 162 - Contract for Health Benefits.

§ 162.  Contract  for  health  benefits.  1.  The  president is hereby authorized and directed to purchase a contract or contracts  to  provide the  benefits  under  the  plan  of  health  benefits determined upon in accordance with  the  provisions  of  this  article.  Such  contract  or contracts  shall  be purchased from one or more corporations licensed to transact accident and health insurance business in this state or subject to article forty-three of the insurance law.  (a) Alternatively, the president may provide health benefits  directly to  plan  participants, in which case the president is hereby authorized to purchase a contract or contracts with one or more firms qualified  to administer,  on New York state health benefit plan's behalf, the plan of benefits required under this article.  (b) In the event the  president  elects  to  provide  health  benefits directly  to  plan participants in accordance with paragraph (a) of this subdivision:  (i) Any and all health insurance coverage mandated by any law, rule or regulation, including but not limited to coverage mandated  pursuant  to article  forty-three  of  the insurance law, applicable to contracts for health insurance entered into under this section shall be provided in  a manner  assuring  uninterrupted  continuance of coverage for all covered persons. For the purposes of this paragraph "coverage" shall include but shall not be limited to all benefits, services, rights,  privileges  and guarantees allowed by law;  (ii)  Plan  participants  shall  be afforded all internal and external review and appeal rights as  described  in  article  forty-nine  of  the insurance law;  (iii)  A  plan  participant  receiving  covered services rendered by a health care provider prior to the date upon which the  president  elects to  provide  health benefits directly to plan participants in accordance with paragraph (a) of this subdivision shall be  permitted  to  continue receiving  services  from  such health care provider after the effective date of the  election  at  the  discretion  of  such  plan  participant. Services  provided by such health care provider after the effective date of the election as described in this paragraph shall  be  covered  in  a manner  consistent  with  covered  services  provided  directly  to plan participants in accordance with paragraph (a) of this subdivision; and  (iv)  Notwithstanding  the  provisions  of   this   subdivision,   the president's  election  to  provide  health  benefits  directly  to  plan participants shall not constitute the doing of insurance business within the meaning of article eleven of the insurance  law;  provided  however, the  provision  of  direct  benefits  as  per  this subdivision shall be subject to review by the superintendent of financial  services  for  the purposes  of  ensuring  compliance with applicable insurance law and any and all associated insurance rules and  regulations  as  noted  in  this subdivision.  (c)  All  of  the  benefits  to  be provided under this article may be included in one or more  similar  contracts,  or  the  benefits  may  be classified  into  different  types  with each type included under one or more similar contracts issued by the same or different companies.   2. A reasonable time before entering into any  insurance  contract  or contract   with   an  administrator  or  administrators  hereunder,  the president  shall  invite  proposals  from  such  qualified  insurers  or administrators  as in his or her opinion would desire to accept any part of the insurance coverage or administrative services authorized by  this article.   3. The president may arrange with any corporation licensed to transact accident  and  health  insurance  business  in  this state or subject to article forty-three of the insurance law issuing any  such  contract  to  reinsure portions of such contract with any other such corporation which elects  to  be  a  reinsurer  and  is  legally competent to enter into a reinsurance agreement.   4. The president may designate one or more of such corporations as the administering corporation or corporations.   5.  Each  employee who is covered under any such contract or contracts shall receive a certificate setting forth  the  benefits  to  which  the employee  and  his  dependents  are  entitled  thereunder,  to whom such benefits shall be payable, to  whom  claims  should  be  submitted,  and summarizing  the  provisions  of  the contract principally affecting the employee and his dependents. Such certificate shall be in  lieu  of  the certificate  which the corporation or corporations issuing such contract or contracts would otherwise issue.   6. The corporations eligible to participate  as  reinsurers,  and  the amount  of  coverage  under the contract or contracts to be allocated to each issuing corporation  or  reinsurer,  may  be  redetermined  by  the president  for  and in advance of any contract year after the first year on a basis consistent with subdivision three of this section,  and  with any  modifications  thereof he deems appropriate to carry out the intent of such subdivision.   7. The president shall not purchase any contract or contracts for  any period except upon the prior approval of the director of the budget.   8.   The  president  may,  on  March  thirty-first,  nineteen  hundred fifty-seven or at the end of any fiscal year thereafter, discontinue any contract  or  contracts  he  has  purchased  from  any  corporation   or corporations  and replace it or them with a contract or contracts in any other corporation or  corporations  meeting  the  requirements  of  this section.   9.  As  soon  as  is  practicable,  but  no  later  than  the first of September, two thousand fourteen, the department  shall,  upon  request, but  no more frequently than semi-annually, provide to any participating employer a standard report which contains data relating to  the  use  of benefits by persons covered under the plan by such employer. Such report shall  include:  premiums  paid  by  month for each month covered in the report and  paid  claims  by  month  for  the  following  categories  of services:  inpatient  hospital, outpatient hospital, in network medical, out of network medical, prescription drugs, and treatment of  behavioral conditions, each reported separately. To the extent allowed by state and federal  privacy laws, such report shall also contain claims information for individual claimants for claims in excess of fifty thousand  dollars that were paid in any of the months covered by the report.   The  department  shall  provide  such  reports  to  any  participating employer, upon request submitted on or after the first of April for data from the first of January through the thirty-first of  December  of  the prior  year,  and  on  or after the first of September for data from the first of June of the prior year through the thirty-first of May  of  the current  year,  within  thirty days of receipt of said request. However, requests submitted in the two thousand fourteen calendar year  shall  be provided  as  soon  as  practicable,  but  no  later  than  the first of September two thousand  fourteen,  or  within  thirty  days  after  said request  if  request  is  submitted  on or after the first of August two thousand fourteen.