§ 4801 — Application

§ 4801. Application. The provisions of this article shall apply to all\nmanaged care products, as defined in subsection (c) of this section,\nwhich are delivered or issued for delivery in this state by insurers\nlicensed under this chapter; provided, however, that none of the\nprovisions of this article shall apply to any health maintenance\norganization lines of business of such insurers or to health maintenance\norganizations certified under article forty-four of the public health\nlaw or licensed under article forty-three of this chapter, which are\nsubject to the provisions of article forty-four of the public health\nlaw. For purposes of this article:\n (a) an "insured" shall mean a person covered under a managed care\nhealth insurance contract.\n (b) an "insurer" shall mean an insurance company subject to article\nthirty-two of this chapter, or a corporation subject to article\nforty-three of this chapter.\n (c) a "managed care health insurance contract" or "managed care\nproduct" shall mean a contract which requires that all medical or other\nhealth care services covered under the contract, other than emergency\ncare services, be provided by, or pursuant to a referral from, a\ndesignated health care provider chosen by the insured (i.e. a primary\ncare gatekeeper), and that services provided pursuant to such a referral\nbe rendered by a health care provider participating in the insurer's\nmanaged care provider network. In addition, in the case of (i) an\nindividual health insurance contract, or (ii) a group health insurance\ncontract covering no more than three hundred lives, imposing a\ncoinsurance obligation of more than twenty-five percent upon services\nreceived outside of the insurer's provider network, and which has been\nsold to five or more groups, a managed care product shall also mean a\ncontract which requires that all medical or other health care services\ncovered under the contract, other than emergency care services, be\nprovided by, or pursuant to a referral from, a designated health care\nprovider chosen by the insured (i.e. a primary care gatekeeper), and\nthat services provided pursuant to such a referral be rendered by a\nhealth care provider participating in the insurer's managed care\nprovider network, in order for the insured to be entitled to the maximum\nreimbursement under the contract.\n (d) "in-network benefits" shall mean benefits covered and received\nunder a managed care product from a health care provider participating\nin the insurer's managed care provider network pursuant to a referral\nfrom the insured's participating primary care gatekeeper.\n