(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.