2023 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.