N.Y. Insurance Law § 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. Such health insurance policy

or contract shall not impose a fee or other penalty for special

enrollment of the pregnant individual. 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.