§ 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.