§ 4322. Standardization of individual enrollee direct payment\ncontracts offered by health maintenance organizations which provide\nout-of-plan benefits prior to October first, two thousand thirteen. (a)\nOn and after January first, nineteen hundred ninety-six, and until\nSeptember thirtieth, two thousand thirteen, all health maintenance\norganizations issued a certificate of authority under article forty-four\nof the public health law or licensed under this article shall offer to\nindividuals, in addition to the standardized contract required by\nsection four thousand three hundred twenty-one of this article, a\nstandardized individual enrollee direct payment contract on an open\nenrollment basis as prescribed by section four thousand three hundred\nseventeen of this article and section four thousand four hundred six of\nthe public health law, and regulations promulgated thereunder, with an\nout-of-plan benefit system, provided, however, that such requirements\nshall not apply to a health maintenance organization exclusively serving\nindividuals enrolled pursuant to title eleven of article five of the\nsocial services law, title eleven-D of article five of the social\nservices law, title one-A of article twenty-five of the public health\nlaw or title eighteen of the federal Social Security Act. The\nout-of-plan benefit system shall either be provided by the health\nmaintenance organization pursuant to subdivision two of section four\nthousand four hundred six of the public health law or through an\naccompanying insurance contract providing out-of-plan benefits offered\nby a company appropriately licensed pursuant to this chapter. On and\nafter January first, nineteen hundred ninety-six, and until September\nthirtieth, two thousand thirteen, the contracts issued pursuant to this\nsection and section four thousand three hundred twenty-one of this\narticle shall be the only contracts offered by health maintenance\norganizations to individuals. The enrollee contracts issued by a health\nmaintenance organization under this section and section four thousand\nthree hundred twenty-one of this article shall also be the only\ncontracts issued by the health maintenance organization for purposes of\nconversion pursuant to sections four thousand three hundred four and\nfour thousand three hundred five of this article. However, nothing in\nthis section shall be deemed to require health maintenance organizations\nto terminate individual direct payment contracts issued prior to January\nfirst, nineteen hundred ninety-six or prohibit health maintenance\norganizations from terminating individual direct payment contracts\nissued prior to January first, nineteen hundred ninety-six.\n (i) On and after January first, two thousand fourteen, each contract\nthat is not a grandfathered health plan shall provide coverage for the\nessential health benefit package. For purposes of this subsection:\n (1) "essential health benefits package" shall have the meaning set\nforth in section 1302(a) of the affordable care act, 42 U.S.C. §\n18022(a); and\n (2) "grandfathered health plan" means coverage provided by a\ncorporation in which an individual was enrolled on March twenty-third,\ntwo thousand ten for as long as the coverage maintains grandfathered\nstatus in accordance with section 1251(e) of the affordable care act, 42\nU.S.C. § 18011(e).\n (b) The in-plan and out-of-plan covered benefits for the standardized\nindividual enrollee direct payment contract shall include coverage for\nall health services which an enrolled population in a health maintenance\norganization might require in order to be maintained in good health,\nrendered without limitation as to time and cost, except to the extent\npermitted by this chapter.\n The in-plan and out-of-plan covered services include the following:\n (1) Inpatient hospital services, including:\n (A) daily room and board;\n (B) general nursing care;\n (C) special diets; and\n (D) miscellaneous hospital serv
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