4801 - Application. - New York Statutes

§ 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.