§ 4321. Standardization of individual enrollee direct payment
contracts offered by health maintenance organizations prior to October
first, two thousand thirteen. (a) On and after January first, nineteen
hundred ninety-six, and until September thirtieth, two thousand thirteen
all health maintenance organizations issued a certificate of authority
under article forty-four of the public health law or licensed under this
article shall offer a standardized individual enrollee contract on an
open enrollment basis as prescribed by section forty-three hundred
seventeen of this article and section forty-four hundred six of the
public health law, and regulations promulgated thereunder, provided,
however, that such requirements shall not apply to a health maintenance
organization exclusively serving individuals enrolled pursuant to title
eleven of article five of the social services law, title eleven-D of
article five of the social services law, title one-A of article
twenty-five of the public health law or title eighteen of the federal
Social Security Act. On and after January first, nineteen hundred
ninety-six, and until September thirtieth, two thousand thirteen, the
enrollee contracts issued pursuant to this section and section four
thousand three hundred twenty-two of this article shall be the only
contracts offered by health maintenance organizations to individuals.
The enrollee contracts issued by a health maintenance organization under
this section and section four thousand three hundred twenty-two of this
article shall also be the only contracts issued by health maintenance
organizations for purposes of conversion pursuant to sections four
thousand three hundred four and four thousand three hundred five of this
article. However, nothing in this section shall be deemed to require
health maintenance organizations to terminate individual direct payment
contracts issued prior to January first, nineteen hundred ninety-six or
prevent health maintenance organizations from terminating individual
direct payment contracts issued prior to January first, nineteen hundred
ninety-six.

(b) The standardized individual enrollee direct payment contract shall
provide coverage for all health services which an enrolled population in
a health maintenance organization might require in order to be
maintained in good health, rendered without limitation as to time and
cost, except to the extent permitted by this chapter; provided however
that no individual enrollee and no family unit enrolled in such
organization shall incur out-of-pocket costs in excess of fifteen
hundred dollars and three thousand dollars, respectively, in any
calendar year. Such covered services shall be identical to the in-plan
covered benefits of the standardized individual direct payment enrollee
contract described in section four thousand three hundred twenty-two of
this article, except as otherwise provided in subsections (c), (d) and
(e) of this section.

(c) The health maintenance organization shall impose a fifteen dollar
copayment on all visits to a physician or other provider with the
exception of visits for pre-natal and post-natal care, well child visits
provided pursuant to paragraph two of subsection (j) of section four
thousand three hundred three of this article, preventive health services
provided pursuant to subparagraph (F) of paragraph four of subsection
(b) of section four thousand three hundred twenty-two of this article,
or items or services for bone mineral density provided pursuant to
subparagraph (D) of paragraph twenty-six of subsection (b) of section
four thousand three hundred twenty-two of this article for which no
copayment shall apply. A copayment of fifteen dollars shall be imposed
on equipment, supplies and self-management education for the treatment
of diabetes. A fifty dollar copayment shall be imposed on emergency
services rendered in the emergency room of a hospital; however, this
copayment must be waived if hospital admission results. Surgical
services shall be subject to a copayment of the lesser of twenty percent
of the cost of such services or two hundred dollars per occurrence. A
five hundred dollar copayment shall be imposed on inpatient hospital
services per continuous hospital confinement. Ambulatory surgical
services shall be subject to a facility copayment charge of seventy-five
dollars. Coinsurance of ten percent shall apply to visits for the
diagnosis and treatment of mental, nervous or emotional disorders or
ailments.

(d) The provisions of each health maintenance organization contract
describing administrative procedures and other provisions not affecting
the scope of, or conditions for obtaining, covered benefits, such as,
but not limited to, eligibility and termination provisions, may be of
the type generally used by the health maintenance organization, as long
as the superintendent determines that the terms and description of those
administrative and other provisions are unlikely to affect consumers'
determinations of which health maintenance organization's contract to
purchase and are not contrary to law. Each contract may also include
limitations and conditions on coverage of benefits described in this
section provided the superintendent determines the limitations and
conditions on coverage were commonly included in health maintenance
organization and/or health insurance products covering individuals on a
direct payment basis prior to January first, nineteen hundred
ninety-six, and are not contrary to law.

(e) The superintendent shall be authorized to modify, by regulation,
the copayments, deductibles and coinsurance amounts described in this
section, if the superintendent determines such amendments are necessary
to moderate potential premiums. On or after January first, nineteen
hundred ninety-eight, the superintendent shall be authorized to
establish one or more additional standardized individual enrollee direct
payment contracts if the superintendent determines, after one or more
public hearings, additional contracts with different levels of benefits
are necessary to meet the needs of the public.

(f) No contract issued pursuant to this section or section four
thousand three hundred twenty-two of this article shall exclude coverage
of a health care service, as defined in paragraph two of subsection (e)
of section four thousand nine hundred of this chapter, rendered or
proposed to be rendered to an insured on the basis that such service is
experimental or investigational, is rendered as part of a clinical trial
as defined in subsection (b-2) of section forty-nine hundred of this
chapter, or a prescribed pharmaceutical product referenced in
subparagraph (B) of paragraph two of subsection (e) of section
forty-nine hundred of this chapter provided that coverage of the patient
costs of such service has been recommended for the insured by an
external appeal agent upon an appeal conducted pursuant to subparagraph
(B) of paragraph four of subsection (b) of section four thousand nine
hundred fourteen of this chapter. The determination of the external
appeal agent shall be binding on the parties. For purposes of this
subsection, patient costs shall have the same meaning as such term has
for purposes of subparagraph (B) of paragraph four of subsection (b) of
section four thousand nine hundred fourteen of this chapter; provided,
however, that coverage for the services required under this subsection
shall be provided subject to the terms and conditions generally
applicable to other benefits provided under the policy.