§ 4321 — Standardization of individual enrollee direct payment contracts offered by health maintenance organizations prior to October first, two t...

New York § 4321

• Jurisdiction: New York
• Law ISC: Insurance
• Art. 43: Non-profit Medical and Dental Indemnity, or Health and Hospital Service Corporations

Text

§ 4321. Standardization of individual enrollee direct payment\ncontracts offered by health maintenance organizations prior to October\nfirst, two thousand thirteen. (a) On and after January first, nineteen\nhundred ninety-six, and until September thirtieth, two thousand thirteen\nall health maintenance organizations issued a certificate of authority\nunder article forty-four of the public health law or licensed under this\narticle shall offer a standardized individual enrollee contract on an\nopen enrollment basis as prescribed by section forty-three hundred\nseventeen of this article and section forty-four hundred six of the\npublic health law, and regulations promulgated thereunder, provided,\nhowever, that such requirements shall not apply to a health maintenance\norganization exclusively serving individuals enrolled pursuant to title\neleven of article five of the social services law, title eleven-D of\narticle five of the social services law, title one-A of article\ntwenty-five of the public health law or title eighteen of the federal\nSocial Security Act. On and after January first, nineteen hundred\nninety-six, and until September thirtieth, two thousand thirteen, the\nenrollee contracts issued pursuant to this section and section four\nthousand three hundred twenty-two of this article shall be the only\ncontracts offered by health maintenance organizations to individuals.\nThe enrollee contracts issued by a health maintenance organization under\nthis section and section four thousand three hundred twenty-two of this\narticle shall also be the only contracts issued by health maintenance\norganizations for purposes of conversion pursuant to sections four\nthousand three hundred four and four thousand three hundred five of this\narticle. However, nothing in this section shall be deemed to require\nhealth maintenance organizations to terminate individual direct payment\ncontracts issued prior to January first, nineteen hundred ninety-six or\nprevent health maintenance organizations from terminating individual\ndirect payment contracts issued prior to January first, nineteen hundred\nninety-six.\n (b) The standardized individual enrollee direct payment contract shall\nprovide coverage for all health services which an enrolled population in\na health maintenance organization might require in order to be\nmaintained in good health, rendered without limitation as to time and\ncost, except to the extent permitted by this chapter; provided however\nthat no individual enrollee and no family unit enrolled in such\norganization shall incur out-of-pocket costs in excess of fifteen\nhundred dollars and three thousand dollars, respectively, in any\ncalendar year. Such covered services shall be identical to the in-plan\ncovered benefits of the standardized individual direct payment enrollee\ncontract described in section four thousand three hundred twenty-two of\nthis article, except as otherwise provided in subsections (c), (d) and\n(e) of this section.\n (c) The health maintenance organization shall impose a fifteen dollar\ncopayment on all visits to a physician or other provider with the\nexception of visits for pre-natal and post-natal care, well child visits\nprovided pursuant to paragraph two of subsection (j) of section four\nthousand three hundred three of this article, preventive health services\nprovided pursuant to subparagraph (F) of paragraph four of subsection\n(b) of section four thousand three hundred twenty-two of this article,\nor items or services for bone mineral density provided pursuant to\nsubparagraph (D) of paragraph twenty-six of subsection (b) of section\nfour thousand three hundred twenty-two of this article for which no\ncopayment shall apply. A copayment of fifteen dollars shall be imposed\non equipment, supplies and self-management education for the treatment\nof diabetes. A fifty dollar copayment shall be imposed on emergency\nservices rendered in the emergency room of a hospital; however, this\ncopayment must be waived if hospital admission results. Surgical\nservices shall be subject to a copayment of the lesser of twenty percent\nof the cost of such services or two hundred dollars per occurrence. A\nfive hundred dollar copayment shall be imposed on inpatient hospital\nservices per continuous hospital confinement. Ambulatory surgical\nservices shall be subject to a facility copayment charge of seventy-five\ndollars. Coinsurance of ten percent shall apply to visits for the\ndiagnosis and treatment of mental, nervous or emotional disorders or\nailments.\n (d) The provisions of each health maintenance organization contract\ndescribing administrative procedures and other provisions not affecting\nthe scope of, or conditions for obtaining, covered benefits, such as,\nbut not limited to, eligibility and termination provisions, may be of\nthe type generally used by the health maintenance organization, as long\nas the superintendent determines that the terms and description of those\nadministrative and other provisions are unlikely to affect consumers'\ndeterminations of which health maintenance organization's contract to\npurchase and are not contrary to law. Each contract may also include\nlimitations and conditions on coverage of benefits described in this\nsection provided the superintendent determines the limitations and\nconditions on coverage were commonly included in health maintenance\norganization and/or health insurance products covering individuals on a\ndirect payment basis prior to January first, nineteen hundred\nninety-six, and are not contrary to law.\n (e) The superintendent shall be authorized to modify, by regulation,\nthe copayments, deductibles and coinsurance amounts described in this\nsection, if the superintendent determines such amendments are necessary\nto moderate potential premiums. On or after January first, nineteen\nhundred ninety-eight, the superintendent shall be authorized to\nestablish one or more additional standardized individual enrollee direct\npayment contracts if the superintendent determines, after one or more\npublic hearings, additional contracts with different levels of benefits\nare necessary to meet the needs of the public.\n (f) No contract issued pursuant to this section or section four\nthousand three hundred twenty-two of this article shall exclude coverage\nof a health care service, as defined in paragraph two of subsection (e)\nof section four thousand nine hundred of this chapter, rendered or\nproposed to be rendered to an insured on the basis that such service is\nexperimental or investigational, is rendered as part of a clinical trial\nas defined in subsection (b-2) of section forty-nine hundred of this\nchapter, or a prescribed pharmaceutical product referenced in\nsubparagraph (B) of paragraph two of subsection (e) of section\nforty-nine hundred of this chapter provided that coverage of the patient\ncosts of such service has been recommended for the insured by an\nexternal appeal agent upon an appeal conducted pursuant to subparagraph\n(B) of paragraph four of subsection (b) of section four thousand nine\nhundred fourteen of this chapter. The determination of the external\nappeal agent shall be binding on the parties. For purposes of this\nsubsection, patient costs shall have the same meaning as such term has\nfor purposes of subparagraph (B) of paragraph four of subsection (b) of\nsection four thousand nine hundred fourteen of this chapter; provided,\nhowever, that coverage for the services required under this subsection\nshall be provided subject to the terms and conditions generally\napplicable to other benefits provided under the policy.\n