N.Y. Insurance Law § 4306-c: Grievance procedure and access to specialty care

§ 4306-c. Grievance procedure and access to specialty care. (a) A

corporation, including a municipal cooperative health benefits plan

certified pursuant to article forty-seven of this chapter, that issues a

comprehensive contract that utilizes a network of providers and is not a

managed care health insurance contract as defined in subsection (c) of

section four thousand eight hundred one of this chapter shall establish

and maintain a grievance procedure consistent with the requirements of

section four thousand eight hundred two of this chapter.

(b) A corporation, including a municipal cooperative health benefits

plan certified pursuant to article forty-seven of this chapter, that

issues a comprehensive contract that utilizes a network of providers and

is not a managed care health insurance contract as defined in subsection

(c) of section four thousand eight hundred one of this chapter and

requires that specialty care be provided pursuant to a referral from a

primary care provider shall provide access to such specialty care

consistent with the requirements of subsections (b), (c) and (d) of

section four thousand eight hundred four of this chapter; provided

however, that nothing in this section shall be construed to require that

a corporation, or a primary care provider on behalf of the corporation,

make a referral to a provider that is not in the corporation's network.

(c) A corporation, including a municipal cooperative health benefits

plan certified pursuant to article forty-seven of this chapter, that

issues a comprehensive contract that utilizes a network of providers and

is not a managed care health insurance contract as defined in subsection

(c) of section four thousand eight hundred one of this chapter shall

provide access to transitional care consistent with the requirements of

subsections (e) and (f) of section four thousand eight hundred four of

this chapter.

(d) A corporation, including a municipal cooperative health benefit

plan certified pursuant to article forty-seven of this chapter and a

student health plan established or maintained pursuant to section one

thousand one hundred twenty-four of this chapter, that issues a

comprehensive policy that utilizes a network of providers and is not a

managed care health insurance contract as defined in subsection (c) of

section four thousand eight hundred one of this chapter, shall provide

access to out-of-network services consistent with the requirements of

subsection (a) of section four thousand eight hundred four of this

chapter, subsections (g-6) and (g-7) of section four thousand nine

hundred of this chapter, subsections (a-1) and (a-2) of section four

thousand nine hundred four of this chapter, paragraphs three and four of

subsection (b) of section four thousand nine hundred ten of this

chapter, and subparagraphs (C) and (D) of paragraph four of subsection

(b) of section four thousand nine hundred fourteen of this chapter.

(e) A corporation, including a municipal cooperative health benefit

plan certified pursuant to article forty-seven of this chapter and a

student health plan established or maintained pursuant to section one

thousand one hundred twenty-four of this chapter as added by chapter 246

of the laws of 2012, that issues a comprehensive policy that uses a

network of providers and is not a managed care health insurance

contract, as defined in subsection (c) of section four thousand eight

hundred one of this chapter, shall establish and maintain procedures for

health care professional applications and terminations consistent with

the requirements of section four thousand eight hundred three of this

chapter and procedures for health care facility applications consistent

with section four thousand eight hundred six of this chapter.