N.Y. Insurance Law § 4801: Application

§ 4801. Application. The provisions of this article shall apply to all

managed care products, as defined in subsection (c) of this section,

which are delivered or issued for delivery in this state by insurers

licensed under this chapter; provided, however, that none of the

provisions of this article shall apply to any health maintenance

organization lines of business of such insurers or to health maintenance

organizations certified under article forty-four of the public health

law or licensed under article forty-three of this chapter, which are

subject to the provisions of article forty-four of the public health

law. For purposes of this article:

(a) an "insured" shall mean a person covered under a managed care

health insurance contract.

(b) an "insurer" shall mean an insurance company subject to article

thirty-two of this chapter, or a corporation subject to article

forty-three of this chapter.

(c) a "managed care health insurance contract" or "managed care

product" shall mean a contract which requires that all medical or other

health care services covered under the contract, other than emergency

care services, be provided by, or pursuant to a referral from, a

designated health care provider chosen by the insured (i.e. a primary

care gatekeeper), and that services provided pursuant to such a referral

be rendered by a health care provider participating in the insurer's

managed care provider network. In addition, in the case of (i) an

individual health insurance contract, or (ii) a group health insurance

contract covering no more than three hundred lives, imposing a

coinsurance obligation of more than twenty-five percent upon services

received outside of the insurer's provider network, and which has been

sold to five or more groups, a managed care product shall also mean a

contract which requires that all medical or other health care services

covered under the contract, other than emergency care services, be

provided by, or pursuant to a referral from, a designated health care

provider chosen by the insured (i.e. a primary care gatekeeper), and

that services provided pursuant to such a referral be rendered by a

health care provider participating in the insurer's managed care

provider network, in order for the insured to be entitled to the maximum

reimbursement under the contract.

(d) "in-network benefits" shall mean benefits covered and received

under a managed care product from a health care provider participating

in the insurer's managed care provider network pursuant to a referral

from the insured's participating primary care gatekeeper.