NY Ins L § 4322 (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4322 - Standardization of Individual Enrollee Direct Payment Contracts Offered by Health Maintenance Organizations Which Provide Out-of-Plan Benefits Prior to October First, Two Thousand Thirteen.

§   4322.   Standardization  of  individual  enrollee  direct  payment contracts offered by  health  maintenance  organizations  which  provide out-of-plan  benefits 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  to individuals,  in  addition  to  the  standardized  contract  required by section four thousand  three  hundred  twenty-one  of  this  article,  a standardized  individual  enrollee  direct  payment  contract on an open enrollment basis as prescribed by section four  thousand  three  hundred seventeen  of this article and section four thousand four hundred six of the public health law, and regulations promulgated thereunder,  with  an out-of-plan  benefit  system,  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.  The out-of-plan benefit system  shall  either  be  provided  by  the  health maintenance  organization  pursuant  to  subdivision two of section four thousand four hundred six  of  the  public  health  law  or  through  an accompanying  insurance  contract providing out-of-plan benefits offered by a company appropriately licensed pursuant to  this  chapter.  On  and after  January  first,  nineteen hundred ninety-six, and until September thirtieth, two thousand thirteen, the contracts issued pursuant to  this section  and  section  four  thousand  three  hundred twenty-one 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-one  of  this  article  shall  also  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.   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  prohibit  health  maintenance organizations  from  terminating  individual  direct  payment  contracts issued prior to January first, nineteen hundred ninety-six.  (i)  On  and after January first, two thousand fourteen, each contract that is not a grandfathered health plan shall provide coverage  for  the essential health benefit package. For purposes of this subsection:  (1)  "essential  health  benefits  package" shall have the meaning set forth in section 1302(a)  of  the  affordable  care  act,  42  U.S.C.  § 18022(a); and  (2)   "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).  (b) The in-plan and out-of-plan covered benefits for the  standardized individual  enrollee  direct payment contract shall include 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.   The in-plan and out-of-plan covered services include the following:  (1) Inpatient hospital services, including:  (A) daily room and board;  (B) general nursing care;  (C) special diets; and  (D) miscellaneous hospital services.  (2) Outpatient hospital services including:  (A) diagnostic and treatment services;  (B) x-rays; and  (C) laboratory tests.  (3) Physician services including:  (A) consultant and referral services;  (B) primary and preventive care services;  (C) in-hospital medical services;  (D) surgical services;  (E) anesthetic services; and  (F) second surgical opinion.  (4) Preventive health services including:  (A) periodic physical examinations, including eye and ear examinations to determine the need for vision and hearing correction;  (B) well child care from birth;  (C) pediatric and adult immunizations;  (D)  mammography  screening,  as provided in subsection (p) of section four thousand three hundred three of this article;  (E) cervical cytology screening  as  provided  in  subsection  (t)  of section four thousand three hundred three of this article; and  (F)  for  a  contract  that  is  not  a grandfathered health plan, the following additional preventive health services:  (i) evidence-based items or services that have in effect a  rating  of 'A'  or  'B'  in  the  current  recommendations  of  the  United  States preventive services task force;  (ii) immunizations that have  in  effect  a  recommendation  from  the advisory  committee on immunization practices of the centers for disease control and prevention with respect to the individual involved;  (iii) with respect to children,  including  infants  and  adolescents, evidence-informed  preventive  care  and  screenings provided for in the comprehensive guidelines supported by the health resources and  services administration; and  (iv)  with  respect  to  women,  such  additional  preventive care and screenings not described  in  item  (i)  of  this  subparagraph  and  as provided  for  in  comprehensive  guidelines  supported  by  the  health resources and services administration.  (v) For purposes of this  subparagraph,  "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).  (5) Emergency services.  (6) Diagnostic laboratory services.  (7) Therapeutic and diagnostic radiologic services.  (8) Preadmission testing.  (9) Home health services up to  two  hundred  visits  per  member  per calendar year.  (10) Maternity care.  (11) Chemotherapy services.  (12)   Hemodialysis   services   consistent  with  the  provisions  of subsection (gg) of section four thousand three  hundred  three  of  this article.  (13) Outpatient physical therapy up to ninety visits per condition per calendar year.  (14) Hospice care up to two hundred ten days.  (15) Skilled nursing facility care when preceded by a hospital stay of at  least  three  days  and  further  hospitalization would otherwise be necessary.  (16)  Equipment,  supplies  and  self-management  education  for   the treatment of diabetes.  (17) Inpatient diagnosis and treatment of mental, nervous or emotional disorders  or ailments up to thirty days per calendar year combined with inpatient treatment of alcoholism and substance abuse.  (18) Inpatient diagnosis and treatment of alcoholism and alcohol abuse and substance abuse and substance  dependence  up  to  thirty  days  per calendar  year  for  detoxification combined with inpatient treatment of mental, nervous or emotional disorders or ailments.  (19)  Outpatient  diagnosis  and  treatment  of  mental,  nervous   or emotional  disorders  or  ailments  up to thirty non-emergency and three emergency visits per calendar year.  (20) Ambulance services.  (21) Private duty nursing up to five thousand dollars  per  individual per  calendar  year  up  to  a  ten  thousand dollar individual lifetime maximum.  (22) Prosthetics, orthotics, durable  medical  equipment  and  medical supplies.  (23) Inpatient physical rehabilitation services.  (24) Blood and blood products.  (25)  Prescription  drugs,  including  contraceptive  drugs or devices approved  by  the  federal  food  and  drug  administration  or  generic equivalents approved as substitutes by such food and drug administration and  nutritional  supplements (formulas), whether administered orally or via a feeding tube for the  therapeutic  treatment  of  phenylketonuria, branched-chain ketonuria, galactosemia and homocystinuria, obtained at a participating  pharmacy  under  a  prescription written by an in-plan or out-of-plan provider. Health maintenance organizations, in  addition  to providing  coverage  for prescription drugs at a participating pharmacy, may utilize a mail order prescription drug program.  Health  maintenance organizations   may  provide  prescription  drugs  pursuant  to  a  drug formulary; however, health maintenance organizations must  implement  an appeals  process so that the use of non-formulary prescription drugs may be requested by a physician or other provider.   Health maintenance organizations shall impose  a  one  hundred  dollar individual  deductible  and a three hundred dollar family deductible per calendar  year  for  prescription  drugs  obtained  at  a  participating pharmacy.  Health  maintenance organizations may not impose a deductible on prescriptions obtained through the mail order drug program.   In addition to the deductible, a ten dollar copayment shall be imposed on up to a thirty-four day  supply  of  brand  name  prescription  drugs obtained  at  a participating pharmacy. A five dollar copayment shall be imposed on up to a thirty-four day supply of generic prescription  drugs or brand name drugs for which there is no generic equivalent obtained at a participating pharmacy.   If  a  mail  order drug program is utilized, a twenty dollar copayment shall be imposed on a ninety  day  supply  of  brand  name  prescription drugs. A ten dollar copayment shall be imposed on a ninety day supply of generic  prescription  drugs  or  brand name drugs for which there is no generic equivalent obtained through the mail order drug program.   In no event shall the copayment exceed  the  cost  of  the  prescribed drug.  (26)  Bone mineral density measurements or tests and, if such contract otherwise includes coverage for prescription drugs,  drugs  and  devices  approved  by  the  federal  food  and  drug  administration  or  generic equivalents as approved substitutes.   In determining appropriate coverage provided by subparagraphs (A), (B) and   (C)   of   this  paragraph,  the  insurer  or  health  maintenance organization shall adopt standards that  include  the  criteria  of  the federal  Medicare program and the criteria of the national institutes of health for the detection of osteoporosis, provided  that  such  coverage shall be further determined as follows:  (A)  For purposes of subparagraphs (B) and (C) of this paragraph, bone mineral density measurements or tests, drugs and devices  shall  include those covered under the criteria of the federal Medicare program as well as  those in accordance with the criteria, of the national institutes of health, including, as consistent with such  criteria  dual-energy  x-ray absorptiometry.  (B)  For purposes of subparagraphs (A) and (C) of this paragraph, bone mineral density measurements  or  tests,  drugs  and  devices  shall  be covered  for  individuals  meeting  the criteria for coverage consistent with the criteria under the federal Medicare program or the criteria  of the  national  institutes  of  health;  provided  that,  to  the  extent consistent with such criteria, individuals qualifying for coverage shall at a minimum, include individuals:  (i) previously diagnosed as having osteoporosis  or  having  a  family history of osteoporosis; or  (ii)  with  symptoms  or conditions indicative of the presence, or the significant risk, of osteoporosis; or  (iii) on a prescribed  drug  regimen  posing  a  significant  risk  of osteoporosis; or  (iv)  with  lifestyle factors to such a degree as posing a significant risk of osteoporosis; or  (v) with such age, gender and/or other  physiological  characteristics which pose a significant risk for osteoporosis.  (C) Such coverage required pursuant to subparagraph (A) or (B) of this paragraph may be subject to annual deductibles and coinsurance as may be deemed  appropriate  by  the  superintendent  and as are consistent with those established for other benefits within a given policy.  (D) In addition to subparagraph (A), (B) or  (C)  of  this  paragraph, except  for  a  grandfathered health plan under subparagraph (E) of this paragraph, coverage  shall  be  provided  for  the  following  items  or services  for  bone  mineral  density,  and  such  coverage shall not be subject to annual deductibles or coinsurance:  (i) evidence-based items or services for  bone  mineral  density  that have  in effect a rating of 'A' or 'B' in the current recommendations of the United States preventive services task force; and  (ii) with respect  to  women,  such  additional  preventive  care  and screenings  for  bone  mineral density not described in item (i) of this subparagraph and as provided for in comprehensive  guidelines  supported by the health resources and services administration.  (E)  For purposes of this paragraph, "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).  (27)  Services  covered  under  such  policy  when   provided   by   a comprehensive  care  center  for  eating  disorders  pursuant to article thirty of the mental hygiene law; provided, however, that  reimbursement under  such policy for services provided through such comprehensive care centers shall, to the extent possible and practicable, be structured  in a  manner to facilitate the individualized, comprehensive and integrated  plans of care which such centers' network of practitioners and providers are required to provide.  (b-1)   The   in-plan   and   out-of-plan  covered  benefits  for  the standardized individual enrollee direct payment contracts established by this section and section four thousand three hundred twenty-one of  this article  shall  not  include  drugs,  procedures  and  supplies  for the treatment of erectile dysfunction when provided to,  or  prescribed  for use  by, a person who is required to register as a sex offender pursuant to article six-C of the correction law, provided that: (1) any denial of coverage pursuant to this subsection shall provide the enrollee with the means of obtaining additional information concerning both the denial and the means of challenging such denial;  (2)  all  drugs,  procedures  and supplies  for  the  treatment  of erectile dysfunction may be subject to prior authorization by health maintenance organizations or insurers  for the purposes of implementing this subsection; and (3) the superintendent shall  promulgate  regulations  to  implement  the  denial  of  coverage pursuant to this subsection giving health maintenance organizations  and insurers  at  least sixty days following promulgation of the regulations to implement their denial procedures pursuant to this subsection.  (b-2) No person or entity authorized to provide  coverage  under  this section  shall be subject to any civil or criminal liability for damages for any decision or action pursuant to subsection (b-1) of this section, made in the ordinary course of business if  that  authorized  person  or entity  acted  reasonably  and  in  good  faith  with  respect  to  such information.  (b-3) Notwithstanding any other provision of law, if the  commissioner of  health  makes  a  finding  pursuant  to  subdivision twenty-three of section two hundred six of the public health law, the superintendent  is authorized  to  remove  a  drug,  procedure  or supply from the services covered by the contracts established by this section  and  section  four thousand  three  hundred  twenty-one  of  this article for those persons required to register as sex offenders pursuant to article six-C  of  the correction law.  (c)  The in-plan benefit system shall impose a ten 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 this section  or items or services for bone mineral density provided pursuant to subparagraph (D) of paragraph twenty-six of subsection  (b)  of  this section  for  which no copayment shall apply. A copayment of ten dollars shall be imposed on equipment, supplies  and  self-management  education for the treatment of diabetes. Coinsurance of ten percent shall apply to visits  for  the diagnosis and treatment of mental, nervous or emotional disorders or ailments. A thirty-five 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.  (d) The out-of-plan benefit system shall  have  an  annual  deductible established  at one thousand dollars per calendar year for an individual and two thousand dollars per year for a  family.  Coinsurance  shall  be established  at  twenty percent with the health maintenance organization or insurer paying eighty percent of the usual, customary and  reasonable charges, or eighty percent of the amounts listed on a fee schedule filed with  and  approved  by  the  superintendent which provides a comparable level of reimbursement.  Coinsurance  of  ten  percent  shall  apply  to outpatient  visits for the diagnosis and treatment of mental, nervous or emotional disorders or ailments. The benefits described in  subparagraph  (F)  of  paragraph  three  and  paragraphs  seventeen  and  eighteen  of subsection (b) of this section shall not be subject to the deductible or coinsurance. The benefits described in paragraph nine of subsection  (b) of  this section shall not be subject to the deductible. The out-of-plan out-of-pocket maximum deductible and coinsurance shall be established at three thousand dollars per calendar year  for  an  individual  and  five thousand  dollars  per  calendar  year  for  a  family.  The out-of-plan lifetime benefit maximum shall be established at five  hundred  thousand dollars  for benefits that are not essential health benefits. A lifetime limit on  the  dollar  amount  of  essential  health  benefits  for  any individual  shall  not  be established. For purposes of this subsection, "essential health benefits" shall have the meaning ascribed  by  section 1302(b) of the Affordable Care Act, 42 U.S.C. § 18022(b).  (e)   The   provisions  of  each  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 issued by the health maintenance organization and/or insurer, 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 the 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.  (f)  A  health  maintenance  organization  may  offer   the   required out-of-plan  benefits by means of a rider to a contract offering in-plan benefits only.  (g) Day and visit limitations on benefits included in this section are aggregate  limitations  regardless  of  whether  services  are  received in-plan  or  out-of-plan.  The  five  thousand dollar per individual per calendar year limitation and ten thousand dollar lifetime limitation  on private  duty  nursing  is  also an aggregate limitation for in-plan and out-of-plan benefits combined.  (h) 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.  (i)  On  and after January first, two thousand fourteen, each contract that is not a grandfathered health plan shall provide coverage  for  the essential health benefit package. For purposes of this subsection:  (1)  "essential  health  benefits  package" shall have the meaning set forth in section 1302(a)  of  the  affordable  care  act,  42  U.S.C.  § 18022(a); and  (2)   "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).