§ 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\nmaintenance organization on and after October first, two thousand\nthirteen. (a) On and after October first, two thousand thirteen, every\nhealth maintenance organization issued a certificate of authority under\narticle forty-four of the public health law or licensed under this\narticle shall offer an individual enrollee direct payment contract in\naccordance with the requirements of this section; provided, however,\nthat this requirement shall not apply to a holder of a special purpose\ncertificate of authority issued pursuant to section four thousand four\nhundred three-a of the public health law, except as otherwise required\nunder subsection (l) of section four thousand three hundred four of this\narticle, or a health maintenance organization exclusively serving\nindividuals enrolled pursuant to title eleven of article five of the\nsocial services law, title eleven-D of article five of the social\nservices law, title one-A of article twenty-five of the public health\nlaw or title eighteen of the federal social security act. The\nsuperintendent may, after giving consideration to the public interest,\nexempt a health maintenance organization from the requirements of this\nsection provided that another health insurer or health maintenance\norganization within the health maintenance organization's same holding\ncompany system, as defined in article fifteen of this chapter, including\na health maintenance organization operated as a line of business of a\nhealth service corporation licensed under this article, offers an\nindividual enrollee direct payment contract that, at a minimum, complies\nwith this section and provides all of the consumer protections required\nto be provided by a health maintenance organization pursuant to the\npublic health law and regulations, including those consumer protections\ncontained in sections four thousand four hundred three and four thousand\nfour hundred eight-a of the public health law. The enrollee contracts\nissued by a health maintenance organization under this section also\nshall be the only contracts issued by the health maintenance\norganization for purposes of conversion pursuant to sections four\nthousand three hundred four and four thousand three hundred five of this\narticle.\n (b) (1) The individual enrollee direct payment contract offered\npursuant to this section shall provide coverage for the essential health\nbenefits package as defined in paragraph three of subsection (e) of\nsection four thousand three hundred six-h of this article.\n (2) A health maintenance organization shall offer at least one\nindividual enrollee direct payment contract at each level of coverage as\ndefined in subsection (b) of section four thousand three hundred six-h\nof this article. A health maintenance organization also shall offer one\nchild-only plan, as required by section 1302(f) of the affordable care\nact, 42 U.S.C. § 18022(f), at each level of coverage.\n (3) Within the health benefit exchange established by this state, a\nhealth maintenance organization may offer an individual enrollee direct\npayment contract that is a catastrophic health plan as defined in\nsection 1302(e) of the affordable care act, 42 U.S.C. § 18022(e), or any\nregulations promulgated thereunder.\n (4) (A) The individual enrollee direct payment contract offered\npursuant to this section shall have the same enrollment periods,\nincluding special enrollment periods, as required for an individual\ndirect payment contract offered within the health benefit exchange\nestablished by this state.\n (B) In addition to the enrollment periods required in subparagraph (A)\nof this paragraph, an individual enrollee direct payment contract\noffered pursuant to this section shall allow for the enrollment of a\npregnant individual. Such individual may enroll at any time after a\nhealth care professional licensed pursuant to title eight of the\neducation law and acting within the scope of his or her practice\ncertifies that the individual is pregnant. Such health insurance policy\nor contract shall not impose a fee or other penalty for special\nenrollment of the pregnant individual. Upon enrollment, coverage shall\nbe effective as of the first day of the month in which the health care\nprofessional certifies that the individual is pregnant, unless the\nindividual elects to have coverage effective on the first day of the\nmonth following the date that the individual received certification of\nthe pregnancy.\n (5) The individual enrollee direct payment contract offered pursuant\nto this section shall be issued without regard to evidence of\ninsurability and without an exclusion for pre-existing conditions.\n (6) A health maintenance organization offering an individual enrollee\ndirect payment contract pursuant to this section shall not establish\nrules for eligibility, including continued eligibility, of any\nindividual or dependent of the individual to enroll under the contract\nbased on any of the following health status-related factors:\n (A) health status;\n (B) medical condition, including both physical and mental illnesses;\n (C) claims experience;\n (D) receipt of health care;\n (E) medical history;\n (F) genetic information;\n (G) evidence of insurability, including conditions arising out of acts\nof domestic violence; or\n (H) disability.\n (7) The individual enrollee direct payment contract offered pursuant\nto this section shall be community rated. For purposes of this\nparagraph, "community rated" means a rating methodology in which the\npremium for all persons covered by a contract form is the same, based on\nthe experience of the entire pool of risks, without regard to age, sex,\nhealth status, tobacco usage, or occupation.\n (c) In addition to or in lieu of the individual enrollee direct\npayment contracts required under this section, all health maintenance\norganizations issued a certificate of authority under article forty-four\nof the public health law or licensed under this article may offer\nindividual enrollee direct payment contracts within the health benefit\nexchange established by this state, subject to any requirements\nestablished by the health benefit exchange. If a health maintenance\norganization satisfies the requirements of subsection (a) of this\nsection by offering individual enrollee direct payment contracts, only\nwithin the health benefit exchange, the health maintenance organization,\nnot including a holder of a special purpose certificate of authority\nissued pursuant to section four thousand four hundred three-a of the\npublic health law, shall also offer at least one individual enrollee\ndirect payment contract at each level of coverage as defined in\nsubsection (b) section four thousand three hundred six-h of this\narticle, outside the health benefit exchange.\n (d)(1) Nothing in this section shall be deemed to require health\nmaintenance organizations to discontinue individual direct payment\ncontracts issued prior to October first, two thousand thirteen or\nprevent health maintenance organizations from discontinuing individual\ndirect payment contracts issued prior to October first, two thousand\nthirteen. If a health maintenance organization discontinues individual\ndirect payment contracts issued prior to October first, two thousand\nthirteen, regardless of whether it is a grandfathered health plan, then\nthe health maintenance organization shall comply with the requirements\nof subsection (c) of section four thousand three hundred four of this\narticle.\n (2) For purposes of this subsection, "grandfathered health plan" means\ncoverage provided by a corporation in which an individual was enrolled\non March twenty-third, two thousand ten for as long as the coverage\nmaintains grandfathered status in accordance with section 1251(e) of the\naffordable care act, 42 U.S.C. § 18011(e).\n (e) The superintendent may promulgate regulations implementing the\nrequirements of this section, including regulations that modify or add\nadditional standardized individual enrollee direct payment contracts if\nthe superintendent determines additional contracts with different levels\nof coverage are necessary to meet the needs of the public.\n