NY Ins L § 4328 (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4328 - Individual Enrollee Direct Payment Contracts Offered by Health Maintenance Organization on and After October First, Two Thousand Thirteen.

§ 4328. Individual enrollee direct payment contracts offered by health maintenance  organization  on  and  after  October  first,  two thousand thirteen. (a) On and after October first, two thousand  thirteen,  every health  maintenance organization issued a certificate of authority under article forty-four of the public  health  law  or  licensed  under  this article  shall  offer  an individual enrollee direct payment contract in accordance with the requirements of  this  section;  provided,  however, that  this  requirement shall not apply to a holder of a special purpose certificate of authority issued pursuant to section four  thousand  four hundred  three-a  of the public health law, except as otherwise required under subsection (l) of section four thousand three hundred four of this article,  or  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.   The superintendent  may,  after giving consideration to the public interest, exempt a health maintenance organization from the requirements  of  this section  provided  that  another  health  insurer  or health maintenance organization within the health maintenance organization's  same  holding company system, as defined in article fifteen of this chapter, including a  health  maintenance  organization operated as a line of business of a health service  corporation  licensed  under  this  article,  offers  an individual enrollee direct payment contract that, at a minimum, complies with  this section and provides all of the consumer protections required to be provided by a health  maintenance  organization  pursuant  to  the public  health law and regulations, including those consumer protections contained in sections four thousand four hundred three and four thousand four hundred eight-a of the public health law.  The  enrollee  contracts issued  by  a  health  maintenance  organization under this section also shall  be  the  only  contracts  issued  by   the   health   maintenance organization  for  purposes  of  conversion  pursuant  to  sections four thousand three hundred four and four thousand three hundred five of this article.  (b) (1)  The  individual  enrollee  direct  payment  contract  offered pursuant to this section shall provide coverage for the essential health benefits  package  as  defined  in  paragraph three of subsection (e) of section four thousand three hundred six-h of this article.  (2) A  health  maintenance  organization  shall  offer  at  least  one individual enrollee direct payment contract at each level of coverage as defined  in  subsection (b) of section four thousand three hundred six-h of this article. A health maintenance organization also shall offer  one child-only  plan,  as required by section 1302(f) of the affordable care act, 42 U.S.C. § 18022(f), at each level of coverage.  (3) Within the health benefit exchange established by  this  state,  a health  maintenance organization may offer an individual enrollee direct payment contract that is  a  catastrophic  health  plan  as  defined  in section 1302(e) of the affordable care act, 42 U.S.C. § 18022(e), or any regulations promulgated thereunder.  (4)  (A)  The  individual  enrollee  direct  payment  contract offered pursuant to  this  section  shall  have  the  same  enrollment  periods, including  special  enrollment  periods,  as  required for an individual direct payment contract  offered  within  the  health  benefit  exchange established by this state.  (B) In addition to the enrollment periods required in subparagraph (A) of  this  paragraph,  an  individual  enrollee  direct  payment contract offered pursuant to this section shall allow for  the  enrollment  of  a pregnant  individual.  Such  individual  may  enroll at any time after a  health care  professional  licensed  pursuant  to  title  eight  of  the education  law  and  acting  within  the  scope  of  his or her practice certifies that the individual is  pregnant.  Upon  enrollment,  coverage shall  be effective as of the first day of the month in which the health care professional certifies that the individual is pregnant, unless  the individual  elects  to  have  coverage effective on the first day of the month following the date that the individual received  certification  of the pregnancy.  (5)  The  individual enrollee direct payment contract offered pursuant to  this  section  shall  be  issued  without  regard  to  evidence   of insurability and without an exclusion for pre-existing conditions.  (6)  A health maintenance organization offering an individual enrollee direct payment contract pursuant to this  section  shall  not  establish rules   for   eligibility,   including  continued  eligibility,  of  any individual or dependent of the individual to enroll under  the  contract based on any of the following health status-related factors:  (A) health status;  (B) medical condition, including both physical and mental illnesses;  (C) claims experience;  (D) receipt of health care;  (E) medical history;  (F) genetic information;  (G) evidence of insurability, including conditions arising out of acts of domestic violence; or  (H) disability.  (7)  The  individual enrollee direct payment contract offered pursuant to  this  section  shall  be  community  rated.  For  purposes  of  this paragraph,  "community  rated"  means  a rating methodology in which the premium for all persons covered by a contract form is the same, based on the experience of the entire pool of risks, without regard to age,  sex, health status, tobacco usage, or occupation.  (c)  In  addition  to  or  in  lieu  of the individual enrollee direct payment contracts required under this section,  all  health  maintenance organizations issued a certificate of authority under article forty-four of  the  public  health  law  or  licensed  under this article may offer individual enrollee direct payment contracts within the  health  benefit exchange   established  by  this  state,  subject  to  any  requirements established by the health benefit  exchange.  If  a  health  maintenance organization  satisfies  the  requirements  of  subsection  (a)  of this section by offering individual enrollee direct payment  contracts,  only within the health benefit exchange, the health maintenance organization, not  including  a  holder  of a special purpose certificate of authority issued pursuant to section four thousand four  hundred  three-a  of  the public  health  law,  shall  also offer at least one individual enrollee direct payment  contract  at  each  level  of  coverage  as  defined  in subsection  (b)  section  four  thousand  three  hundred  six-h  of this article, outside the health benefit exchange.  (d)(1) Nothing in this section  shall  be  deemed  to  require  health maintenance  organizations  to  discontinue  individual  direct  payment contracts issued prior  to  October  first,  two  thousand  thirteen  or prevent  health  maintenance organizations from discontinuing individual direct payment contracts issued prior to  October  first,  two  thousand thirteen.  If  a health maintenance organization discontinues individual direct payment contracts issued prior to  October  first,  two  thousand thirteen,  regardless of whether it is a grandfathered health plan, then the health maintenance organization shall comply with  the  requirements of  subsection  (c)  of section four thousand three hundred four of this article.  (2) For purposes of this subsection, "grandfathered health plan" means coverage provided by a corporation in which an individual  was  enrolled on  March  twenty-third,  two  thousand  ten for as long as the coverage maintains grandfathered status in accordance with section 1251(e) of the affordable care act, 42 U.S.C. § 18011(e).  (e)  The  superintendent  may  promulgate regulations implementing the requirements of this section, including regulations that modify  or  add additional  standardized individual enrollee direct payment contracts if the superintendent determines additional contracts with different levels of coverage are necessary to meet the needs of the public.