N.Y. Insurance Law § 4321: Standardization of individual enrollee direct payment contracts offered by health maintenance organizations prior to October first, two t...

§ 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.