New York Consolidated Laws, Insurance Law - ISC § 4801. Application

(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.