NY Ins L § 4321 (2021)
2021 New York Laws ISC - Insurance Article 43 - 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 Prior to October First, Two Thousand Thirteen.

§   4321.   Standardization  of  individual  enrollee  direct  payment contracts offered by health maintenance organizations prior  to  October first,  two  thousand thirteen. (a) On and after January first, nineteen hundred ninety-six, and until September thirtieth, two thousand thirteen 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.  On  and  after  January  first,  nineteen  hundred ninety-six,  and  until  September thirtieth, two thousand thirteen, 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.