2023 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.