§ 4328. Individual enrollee direct payment contracts offered by health
maintenance organization on and after October first, two thousand
thirteen. (a) On and after October first, two thousand thirteen, every
health maintenance organization issued a certificate of authority under
article forty-four of the public health law or licensed under this
article shall offer an individual enrollee direct payment contract in
accordance with the requirements of this section; provided, however,
that this requirement shall not apply to a holder of a special purpose
certificate of authority issued pursuant to section four thousand four
hundred three-a of the public health law, except as otherwise required
under subsection (l) of section four thousand three hundred four of this
article, or 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. The
superintendent may, after giving consideration to the public interest,
exempt a health maintenance organization from the requirements of this
section provided that another health insurer or health maintenance
organization within the health maintenance organization's same holding
company system, as defined in article fifteen of this chapter, including
a health maintenance organization operated as a line of business of a
health service corporation licensed under this article, offers an
individual enrollee direct payment contract that, at a minimum, complies
with this section and provides all of the consumer protections required
to be provided by a health maintenance organization pursuant to the
public health law and regulations, including those consumer protections
contained in sections four thousand four hundred three and four thousand
four hundred eight-a of the public health law. The enrollee contracts
issued by a health maintenance organization under this section also
shall be the only contracts issued by the health maintenance
organization for purposes of conversion pursuant to sections four
thousand three hundred four and four thousand three hundred five of this
article.

(b) (1) The individual enrollee direct payment contract offered
pursuant to this section shall provide coverage for the essential health
benefits package as defined in paragraph three of subsection (e) of
section four thousand three hundred six-h of this article.

(2) A health maintenance organization shall offer at least one
individual enrollee direct payment contract at each level of coverage as
defined in subsection (b) of section four thousand three hundred six-h
of this article. A health maintenance organization also shall offer one
child-only plan, as required by section 1302(f) of the affordable care
act, 42 U.S.C. § 18022(f), at each level of coverage.

(3) Within the health benefit exchange established by this state, a
health maintenance organization may offer an individual enrollee direct
payment contract that is a catastrophic health plan as defined in
section 1302(e) of the affordable care act, 42 U.S.C. § 18022(e), or any
regulations promulgated thereunder.

(4) (A) The individual enrollee direct payment contract offered
pursuant to this section shall have the same enrollment periods,
including special enrollment periods, as required for an individual
direct payment contract offered within the health benefit exchange
established by this state.

* (B) In addition to the enrollment periods required in subparagraph
(A) of this paragraph, an individual enrollee direct payment contract
offered pursuant to this section shall allow for the enrollment of a
pregnant individual. Such individual may enroll at any time after a
health care professional licensed pursuant to title eight of the
education law and acting within the scope of his or her practice
certifies that the individual is pregnant. Upon enrollment, coverage
shall be effective as of the first day of the month in which the health
care professional certifies that the individual is pregnant, unless the
individual elects to have coverage effective on the first day of the
month following the date that the individual received certification of
the pregnancy.

* NB Effective until January 1, 2025

* (B) In addition to the enrollment periods required in subparagraph
(A) of this paragraph, an individual enrollee direct payment contract
offered pursuant to this section shall allow for the enrollment of a
pregnant individual. Such individual may enroll at any time after a
health care professional licensed pursuant to title eight of the
education law and acting within the scope of his or her practice
certifies that the individual is pregnant. Such health insurance policy
or contract shall not impose a fee or other penalty for special
enrollment of the pregnant individual. Upon enrollment, coverage shall
be effective as of the first day of the month in which the health care
professional certifies that the individual is pregnant, unless the
individual elects to have coverage effective on the first day of the
month following the date that the individual received certification of
the pregnancy.

* NB Effective January 1, 2025

(5) The individual enrollee direct payment contract offered pursuant
to this section shall be issued without regard to evidence of
insurability and without an exclusion for pre-existing conditions.

(6) A health maintenance organization offering an individual enrollee
direct payment contract pursuant to this section shall not establish
rules for eligibility, including continued eligibility, of any
individual or dependent of the individual to enroll under the contract
based on any of the following health status-related factors:

(A) health status;

(B) medical condition, including both physical and mental illnesses;

(C) claims experience;

(D) receipt of health care;

(E) medical history;

(F) genetic information;

(G) evidence of insurability, including conditions arising out of acts
of domestic violence; or

(H) disability.

(7) The individual enrollee direct payment contract offered pursuant
to this section shall be community rated. For purposes of this
paragraph, "community rated" means a rating methodology in which the
premium for all persons covered by a contract form is the same, based on
the experience of the entire pool of risks, without regard to age, sex,
health status, tobacco usage, or occupation.

(c) In addition to or in lieu of the individual enrollee direct
payment contracts required under this section, all health maintenance
organizations issued a certificate of authority under article forty-four
of the public health law or licensed under this article may offer
individual enrollee direct payment contracts within the health benefit
exchange established by this state, subject to any requirements
established by the health benefit exchange. If a health maintenance
organization satisfies the requirements of subsection (a) of this
section by offering individual enrollee direct payment contracts, only
within the health benefit exchange, the health maintenance organization,
not including a holder of a special purpose certificate of authority
issued pursuant to section four thousand four hundred three-a of the
public health law, shall also offer at least one individual enrollee
direct payment contract at each level of coverage as defined in
subsection (b) section four thousand three hundred six-h of this
article, outside the health benefit exchange.

(d)(1) Nothing in this section shall be deemed to require health
maintenance organizations to discontinue individual direct payment
contracts issued prior to October first, two thousand thirteen or
prevent health maintenance organizations from discontinuing individual
direct payment contracts issued prior to October first, two thousand
thirteen. If a health maintenance organization discontinues individual
direct payment contracts issued prior to October first, two thousand
thirteen, regardless of whether it is a grandfathered health plan, then
the health maintenance organization shall comply with the requirements
of subsection (c) of section four thousand three hundred four of this
article.

(2) For purposes of this subsection, "grandfathered health plan" means
coverage provided by a corporation in which an individual was enrolled
on March twenty-third, two thousand ten for as long as the coverage
maintains grandfathered status in accordance with section 1251(e) of the
affordable care act, 42 U.S.C. § 18011(e).

(e) The superintendent may promulgate regulations implementing the
requirements of this section, including regulations that modify or add
additional standardized individual enrollee direct payment contracts if
the superintendent determines additional contracts with different levels
of coverage are necessary to meet the needs of the public.