New York Laws
Article 11 - Health Benefits for State and Retired State Employees
162 - Contract for Health Benefits.

(a) Alternatively, the president may provide health benefits directly
to plan participants, in which case the president is hereby authorized
to purchase a contract or contracts with one or more firms qualified to
administer, on New York state health benefit plan's behalf, the plan of
benefits required under this article.
(b) In the event the president elects to provide health benefits
directly to plan participants in accordance with paragraph (a) of this
subdivision:
(i) Any and all health insurance coverage mandated by any law, rule or
regulation, including but not limited to coverage mandated pursuant to
article forty-three of the insurance law, applicable to contracts for
health insurance entered into under this section shall be provided in a
manner assuring uninterrupted continuance of coverage for all covered
persons. For the purposes of this paragraph "coverage" shall include but
shall not be limited to all benefits, services, rights, privileges and
guarantees allowed by law;
(ii) Plan participants shall be afforded all internal and external
review and appeal rights as described in article forty-nine of the
insurance law;
(iii) A plan participant receiving covered services rendered by a
health care provider prior to the date upon which the president elects
to provide health benefits directly to plan participants in accordance
with paragraph (a) of this subdivision shall be permitted to continue
receiving services from such health care provider after the effective
date of the election at the discretion of such plan participant.
Services provided by such health care provider after the effective date
of the election as described in this paragraph shall be covered in a
manner consistent with covered services provided directly to plan
participants in accordance with paragraph (a) of this subdivision; and
(iv) Notwithstanding the provisions of this subdivision, the
president's election to provide health benefits directly to plan
participants shall not constitute the doing of insurance business within
the meaning of article eleven of the insurance law; provided however,
the provision of direct benefits as per this subdivision shall be
subject to review by the superintendent of financial services for the
purposes of ensuring compliance with applicable insurance law and any
and all associated insurance rules and regulations as noted in this
subdivision.
(c) All of the benefits to be provided under this article may be
included in one or more similar contracts, or the benefits may be
classified into different types with each type included under one or
more similar contracts issued by the same or different companies.
2. A reasonable time before entering into any insurance contract or
contract with an administrator or administrators hereunder, the
president shall invite proposals from such qualified insurers or
administrators as in his or her opinion would desire to accept any part
of the insurance coverage or administrative services authorized by this
article.
3. The president may arrange with any corporation licensed to transact
accident and health insurance business in this state or subject to
article forty-three of the insurance law issuing any such contract to

reinsure portions of such contract with any other such corporation which
elects to be a reinsurer and is legally competent to enter into a
reinsurance agreement.
4. The president may designate one or more of such corporations as the
administering corporation or corporations.
5. Each employee who is covered under any such contract or contracts
shall receive a certificate setting forth the benefits to which the
employee and his dependents are entitled thereunder, to whom such
benefits shall be payable, to whom claims should be submitted, and
summarizing the provisions of the contract principally affecting the
employee and his dependents. Such certificate shall be in lieu of the
certificate which the corporation or corporations issuing such contract
or contracts would otherwise issue.
6. The corporations eligible to participate as reinsurers, and the
amount of coverage under the contract or contracts to be allocated to
each issuing corporation or reinsurer, may be redetermined by the
president for and in advance of any contract year after the first year
on a basis consistent with subdivision three of this section, and with
any modifications thereof he deems appropriate to carry out the intent
of such subdivision.
7. The president shall not purchase any contract or contracts for any
period except upon the prior approval of the director of the budget.
8. The president may, on March thirty-first, nineteen hundred
fifty-seven or at the end of any fiscal year thereafter, discontinue any
contract or contracts he has purchased from any corporation or
corporations and replace it or them with a contract or contracts in any
other corporation or corporations meeting the requirements of this
section.
9. As soon as is practicable, but no later than the first of
September, two thousand fourteen, the department shall, upon request,
but no more frequently than semi-annually, provide to any participating
employer a standard report which contains data relating to the use of
benefits by persons covered under the plan by such employer. Such report
shall include: premiums paid by month for each month covered in the
report and paid claims by month for the following categories of
services: inpatient hospital, outpatient hospital, in network medical,
out of network medical, prescription drugs, and treatment of behavioral
conditions, each reported separately. To the extent allowed by state and
federal privacy laws, such report shall also contain claims information
for individual claimants for claims in excess of fifty thousand dollars
that were paid in any of the months covered by the report.
The department shall provide such reports to any participating
employer, upon request submitted on or after the first of April for data
from the first of January through the thirty-first of December of the
prior year, and on or after the first of September for data from the
first of June of the prior year through the thirty-first of May of the
current year, within thirty days of receipt of said request. However,
requests submitted in the two thousand fourteen calendar year shall be
provided as soon as practicable, but no later than the first of
September two thousand fourteen, or within thirty days after said
request if request is submitted on or after the first of August two
thousand fourteen.