NY Ins L § 4305 (2021)
2021 New York Laws ISC - Insurance Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations 4305 - Group Contracts.

§  4305.  Group contracts. (a) A corporation subject to the provisions of this article may issue  a  group  contract,  provided  the  group  of persons  thereby covered conforms to the requirements of subsections (c) and  (d)  of  section  four  thousand  two  hundred  thirty-five  or  of subparagraph  (C)  of  paragraph three of subsection (a) of section four thousand two hundred thirty-seven of this  chapter,  and  provided  such contract  and the individual certificates issued to members of the group shall comply in substance with this article. A  corporation  subject  to the  provisions of this article shall issue to the group contractholder, for delivery to each  member  of  the  insured  group,  a  copy  of  the contract, or a certificate which can be in the form of a booklet setting forth  in  summary  form  a  statement  of the essential features of the insurance coverage. A group contract issued  pursuant  to  this  section shall be subject to subsections (k) and (l) of section four thousand two hundred thirty-five of this chapter.  (b) Any such contract which provides for the adjustment of the rate of premium  based upon the experience thereunder shall specify the duration of the period of insurance thereunder;  such  period  shall  not  exceed three  years, provided, however, that such contract may provide that, in the absence of one month's prior written notice by either party  to  the other,  it  shall  be  automatically  renewed  at the termination of any period thereunder for a succeeding period of not less than one nor  more than  three  years'  duration.  In any case where such contract is for a period of more than one year, an appropriate additional rate of  premium shall  be  charged  therefor.  Any  such  contract  may  provide for the adjustment of the rate of premium based upon the  experience  thereunder at  the end of the first period of insurance thereunder or at the end of any subsequent period of insurance thereunder and  any  such  adjustment may  be  made  retroactive  only for the period of insurance immediately preceding such adjustment.  (c) (1)(A) Any  such  contract  may  provide  that  benefits  will  be furnished  to  a member of a covered group, for the member, the member's spouse, child or children, or other persons chiefly dependent  upon  the member for support and maintenance; provided that:  (i)  a  contract  of hospital, medical, surgical, or prescription drug expense insurance that provides coverage for children shall provide such coverage to a  married  or  unmarried  child  until  attainment  of  age twenty-six,  without  regard to financial dependence, residency with the member, student status, or employment,  except  a  contract  that  is  a grandfathered  health  plan may, for plan years beginning before January first, two thousand fourteen, exclude coverage of an adult  child  under age twenty-six who is eligible to enroll in an employer-sponsored health plan  other  than  a group health plan of a parent. For purposes of this item,  "grandfathered  health  plan"  means  coverage  provided   by   a corporation  in  which an individual was enrolled on March twenty-third, two thousand ten for as long as  the  coverage  maintains  grandfathered status in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e); and  (ii)  a  contract  under  which coverage terminates at a specified age shall,  with  respect  to  an  unmarried  child  who  is  incapable   of self-sustaining  employment  by  reason of mental illness, developmental disability, mental retardation, as defined in the mental hygiene law, or physical handicap and who became so incapable prior to attainment of the age at which coverage would  otherwise  terminate  and  who  is  chiefly dependent upon such member for support and maintenance, not so terminate while  the  contract  remains  in  force  and  the child remains in such condition, if the member has within  thirty-one  days  of  such  child's  attainment  of  the  termination  age  submitted  proof  of such child's incapacity as described herein.  (B)  In  addition  to  the  requirements  of  subparagraph (A) of this paragraph, every corporation  issuing  a  group  contract  of  hospital, medical  or  surgical  expense  insurance  pursuant to this section that provides coverage for children, must make available and if requested  by the  contractholder, extend coverage under that contract to an unmarried child through age twenty-nine, without regard  to  financial  dependence who is not insured by or eligible for coverage under any employer health benefit  plan as an employee or member, whether insured or self-insured, and who lives, works or resides in New York state or the service area of the corporation. Such coverage shall be made available at the  inception of  all  new  contracts  and  with respect to all other contracts at any anniversary date. Written notice of the availability  of  such  coverage shall  be delivered to the contractholder prior to the inception of such group contract and annually thereafter.  (C) Notwithstanding any rule, regulation or law to the  contrary,  any contract  under  which  a  member  elects  coverage  for the member, the member's spouse, children or other persons chiefly  dependent  upon  the member  for  support  and  maintenance  shall  provide  that coverage of newborn infants, including newly born infants adopted by the  member  if such  member  takes  physical  custody  of the infant upon such infant's release from the hospital and files a petition pursuant to  section  one hundred  fifteen-c  of  the domestic relations law within thirty days of birth; and provided further that no notice of revocation to the adoption has been filed pursuant to section one hundred fifteen-b of the domestic relations law and consent to the adoption has not been revoked, shall be effective from the moment of birth for injury or sickness including  the necessary  care  and treatment of medically diagnosed congenital defects and birth abnormalities including premature birth, except that in  cases of adoption, coverage of the initial hospital stay shall not be required where  a  birth parent has insurance coverage available for the infant's care. This provision regarding coverage of  newborn  infants  shall  not apply  to  two  person coverage. In the case of individual or two person coverages the corporation must  also  permit  the  person  to  whom  the certificate is issued to elect such coverage of newborn infants from the moment of birth. If notification and/or payment of an additional premium or  contribution  is  required  to make coverage effective for a newborn infant, the coverage may provide that such notice and/or payment be made within no less than thirty days of the day of  birth  to  make  coverage effective  from the moment of birth. This election shall not be required in the case of student insurance or where  the  group's  plan  does  not provide coverage for children.  (2)  Any  such  contract under which coverage of a dependent spouse or group member would terminate upon such spouse or group member  attaining the  age  prescribed  in subchapter XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. ("Medicare"), as the age of first eligibility  for the  benefits  provided  by  such  law  shall  not so terminate, if such dependent spouse is not then eligible for all of such benefits,  for  as long  as the contract remains in force and such dependent spouse remains ineligible to receive any of such "Medicare" benefits, provided proof of such ineligibility is submitted to  the  corporation  within  thirty-one days  of  the  date  notice  of termination of coverage is sent by first class mail  by  the  corporation  to  the  last  known  address  of  the policyholder.  (d)  (1)  (A)  A  group contract issued pursuant to this section shall contain a provision to the effect that  in  case  of  a  termination  of coverage  under  such contract of any member of the group because of (i)  termination for any reason whatsoever  of  the  member's  employment  or membership,  or  (ii) termination for any reason whatsoever of the group contract itself unless the group contract holder has replaced the  group contract with similar and continuous coverage for the same group whether insured  or self-insured, the member shall be entitled to have issued to the member by the corporation, without evidence  of  insurability,  upon application  therefor  and  payment  of  the  first  premium made to the corporation within sixty days after  termination  of  the  coverage,  an individual  direct  payment  contract,  covering  such  member  and  the member's eligible dependents who were covered  by  the  group  contract, which  provides  coverage  that  contains  the essential health benefits package described in paragraph three of subsection (e) of  section  four thousand  three  hundred  six-h  of  this article. The corporation shall offer one contract at each level of coverage as  defined  in  subsection (b)  of  section  four thousand three hundred six-h of this article. The member  may  choose  any  such  contract  offered  by  the  corporation. Provided,   however,   the   superintendent   may,   after   giving  due consideration to the public  interest,  approve  a  request  made  by  a corporation  for  the  corporation  to  satisfy the requirements of this subparagraph through the offering of contracts  that  comply  with  this subparagraph  by  another  corporation,  insurer  or  health maintenance organization within the corporation's same holding  company  system,  as defined in article fifteen of this chapter.  (B)  The conversion privilege afforded in this paragraph shall also be available: (i) upon the divorce  or  annulment  of  the  marriage  of  a member,  to  the  divorced  spouse or former spouse of such member; (ii) upon the death  of  the  member,  to  the  surviving  spouse  and  other dependents  covered  under  the contract; and (iii) to a dependent if no longer within the definition in the contract.  (2) The effective date of the  coverage  provided  by  the  individual direct  payment  contract  shall  be  the date of the termination of the individual's coverage under the group contract.  The  corporation  shall not  be  required  to  issue  such  individual  direct payment converted contract covering any person if it appears that such person  shall  then be  covered by another individual contract providing similar coverage or if it shall appear that such person is covered  by  or  eligible  to  be covered  by  a group contract or policy providing similar benefits or is provided with similar benefits required by any statute  or  provided  by any  welfare  plan or program, which together with the individual direct payment converted contract would result in over-insurance or duplication of benefits according to standards on file with  the  superintendent  of financial services relating to individual contracts.  (3)  (A)  Each  member  in  the insured group, but not his dependents, shall be given written notice of such conversion privilege  provided  in paragraph one hereof and its duration within fifteen days after the date of  termination  of  coverage under the group contract, provided that if such notice be given more than fifteen days but less  than  ninety  days after  the  date of termination of coverage under the group contract the time allowed for the exercise of  such  conversion  privilege  shall  be extended  for  forty-five  days after the giving of such notice. If such notice is not given within ninety days after the date of termination  of coverage  under  the group contract the time allowed for the exercise of such conversion privilege shall expire at the end of such ninety days.  (B) Written notice by the contract holder given to the member or  sent by  first class mail to the member at his last known address, or written notice by the corporation which issued the group contract sent by  first class  mail  to  the  member  at  the  last  address  furnished  to  the  corporation by the contract holder, shall be deemed full compliance with the provisions of this paragraph for the giving of notice.  (C)  A  group  contract  issued pursuant to this section may contain a provision to the effect that notice of such conversion privilege and its duration shall be given by  the  contract  holder  to  each  certificate holder upon termination of his group coverage.  (4)  A  group  contract  to  be  issued  to a social services district pursuant to section three hundred sixty-five of the social services  law by  a  corporation  subject  to the provisions of this article need not, subject to the approval of the superintendent, provide for the  issuance of  individual  certificates  and  may  omit  or modify any of the other provisions required to be contained in such contract, provided that  the superintendent  deems  such  omission  or  modification suitable for the character of the coverage provided.  (5) For purposes  of  this  subsection,  the  term  "dependent"  shall include a child as described in subsection (c) of this section.  (e) In addition to the conversion privilege afforded by subsection (d) of  this  section, a group contract issued by a hospital service, health service or medical expense indemnity corporation shall provide  that  if all  or  any  portion  of the insurance on an employee or member insured under  the  policy  ceases  because  of  termination  of  employment  or membership  in  the  class  or  classes  eligible for coverage under the policy, such employee or member shall be entitled  without  evidence  of insurability  upon  application to continue his insurance for himself or herself and his or her eligible dependents, subject to all of the  group contract's  terms  and  conditions applicable to those forms of benefits and to the following conditions:  (1) Continuation shall cease on the date which the employee, member or dependant first becomes, after the date of  election:  (A)  entitled  to coverage  under  title  XVIII  of  the United States Social Security Act (Medicare) as amended or superseded; or  (B)  covered  as  an  employee, member  or dependent by any other insured or uninsured arrangement which provides hospital, surgical or medical coverage  for  individuals  in  a group which does not contain any exclusion or limitation with respect to any pre-existing condition of such employee, member or dependent.  (2) (A) An employee or member who wishes continuation of coverage must request  such  continuation  in  writing  within  the  sixty  day period following the later of: (i) the date of such termination;  or  (ii)  the date  the  employee  is  sent notice by first class mail of the right of continuation by the group policyholder.  (B) An employee or member who wishes continuation  of  coverage  under subparagraph  (D)  of paragraph four of this subsection must give notice to  the  employer  or  group  policyholder  within  sixty  days  of  the determination  under  title  II or title XVI of the United States Social Security Act that such employee or member was disabled at  the  time  of termination  of employment or membership or at any time during the first sixty days of continuation of coverage.  (3) An employee or member electing continuation must pay to the  group policyholder  or his employer, but not more frequently than on a monthly basis in advance, the amount of the required premium  payment,  but  not more  than  one  hundred  two percent of the group rate for the benefits being continued under the  group  contract  on  the  due  date  of  each payment.  The  employee's  or member's written election of continuation, together with the first premium payment required  to  establish  premium payment on a monthly basis in advance, must be given to the policyholder or  employer  within  sixty  days of the date the employee's or member's benefits would otherwise terminate.  (4) Subject to paragraph  one  of  this  subsection,  continuation  of benefits  under the group contract for any person shall terminate at the first to occur of the following:  (A)  The  date  thirty-six  months  after  the  date the employee's or member's benefits under the contract  would  otherwise  have  terminated because of termination of employment or membership; or  (B) The end of the period for which premium payments were made, if the employee  or  member  fails to make timely payment of a required premium payment; or  (C) In the case of an eligible dependent of an employee or member, the date thirty-six months after the date such person's benefits  under  the contract would otherwise have terminated by reason of:  (i) the death of the employee or member;  (ii)  the  divorce  or legal separation of the employee or member from his or her spouse;  (iii) the employee or member becoming entitled to benefits under title XVIII of the United States Social Security Act (Medicare); or  (iv) a dependent child ceasing to  be  a  dependent  child  under  the generally applicable requirements of the contract; or  (D) The date on which the group contract is terminated or, in the case of an employee, the date his employer terminated participation under the group contract. However, if this clause applies and the coverage ceasing by  reason  of  such  termination  is replaced by similar coverage under another group contract, the following shall apply:  (i) The employee or member shall have  the  right  to  become  covered under  that  other group contract, for the balance of the period that he would have remained covered under the prior group contract in accordance with this subparagraph had a termination described in this  subparagraph not occurred, and  (ii)  The  minimum level of benefits to be provided by the other group contract shall be the applicable level of benefits of  the  prior  group contract reduced by any benefits payable under the prior group contract, and  (iii)  The  prior group contract shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits  as  if the replacement had not occurred.  (5)  A  notification of the continuation privilege and the time period in which to request continuation shall be included in  each  certificate of coverage.  (6)  The  conversion  privilege  afforded  by  subsection  (d) of this section shall be available  upon  termination  of  the  continuation  of benefits described herein.  (7)  This  subsection  shall  not  be  applicable where a continuation benefit is available to the employee or member pursuant to Chapter 18 of the Employee Retirement Income Security Act, 29 U.S.C. § 1161 et seq  or Chapter  6A  of the Public Health Service Act, 42 U.S.C. § 300 bb - 1 et seq. However, a group contract shall offer an employee or member who has exhausted continuation coverage pursuant to Chapter 18 of  the  Employee Retirement  Income  Security Act, 29 U.S.C. § 1161 et seq. or Chapter 6A of the Public Health Service Act, 42 U.S.C. § 300 bb -  1  et  seq.  the opportunity  to  continue  coverage for up to thirty-six months from the date the employee's or  member's  continuation  coverage  began  if  the employee  or  member  is  entitled  to  less  than  thirty-six months of continuation benefits.  (8)(A) Special enrollment period. An individual who does not  have  an election  of  continuation  coverage  as described in this subsection in effect on the effective date of the American Recovery  and  Reinvestment act  of  2009,  but who would be an assistance eligible individual under  Title III of such act  if  such  election  were  in  effect,  may  elect continuation coverage pursuant to this subsection. Such election must be made  no  later  than sixty days after the date the administrator of the group  health  plan  (or  other  entity  involved)  provides  the notice required by section 3001(a)(7) of the American Recovery and Reinvestment act of 2009. The administrator of the group health plan (or other entity involved) shall provide such individuals with additional notice  of  the right  to elect coverage pursuant to this paragraph within sixty days of the date of enactment of the American Recovery and Reinvestment  act  of 2009.  (B) Continuation coverage elected pursuant to subparagraph (A) of this paragraph  shall commence with the first period of coverage beginning on or after the  date  of  the  enactment  of  the  American  Recovery  and Reinvestment  act  of  2009  and  shall  not extend beyond the period of continuation coverage that would have been required if the coverage  had instead been elected pursuant to paragraph two of this subsection.  (C)  With  respect  to  an individual who elects continuation coverage pursuant to subparagraph (A) of this paragraph, the period beginning  on the  date  of  the  qualifying event and ending on the date of the first period of coverage on or after the enactment of  the  American  Recovery and  Reinvestment  act  of  2009  shall  be  disregarded for purposes of determining the sixty-three day  period  referred  to  in  section  four thousand three hundred eighteen of this article.  (9)  For  purposes  of  this  subsection,  the  term "dependent" shall include a child as described in subsection (c) of this section.  (f) Any contract and certificate, other than one issued in fulfillment of the continuing care responsibilities of an operator of  a  continuing care  retirement  community  in accordance with article forty-six of the public health law, made available because of residence in  a  particular facility,  housing development, or community shall contain the following notice in twelve point type in bold face on the first page:   "NOTICE - THIS CONTRACT (CERTIFICATE) DOES NOT MEET  THE  REQUIREMENTS OF  A CONTINUING CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE  RETIREMENT COMMUNITY."  (g)  In  addition  to  all  the  rights of conversion and continuation otherwise provided for herein, employees or members  insured  under  the contract who are also members of a reserve component of the armed forces of the United States, including the National Guard, shall be entitled to have   supplementary  conversion  and  continuation  rights  in  certain circumstances as follows:  (1) if the employee or member  insured  enters  upon  active  duty  as defined  in  subsection  (h)  of this section, and the employer or group contract holder does not voluntarily maintain coverage for such employee or member insured, the employee or member insured shall be  entitled  to have  his  or  her  coverage  continued  under  the  group  contract  in accordance with the conditions and limitations  contained  in  paragraph seven  of  this  subsection  and have issued at the end of the period of continuation an individual conversion policy subject  to  the  terms  of this  subsection.  The effective date for the conversion policy shall be the day following the termination of insurance under the  group  policy, or  if there is a continuation of coverage, on the day following the end of the period of continuation.  (2) if the employer or group  contract  holder  does  not  voluntarily maintain  coverage  for the employee or member insured during the period of active duty, and such employee or member insured does not  elect  the supplementary  conversion  and  continuation rights provided for herein,  coverage for such employee or member insured shall be  suspended  during the period of active duty.  (3)  if  the  employee  or  member  insured  elects  the supplementary continuation right provided for herein or coverage under the group  plan is suspended, and such employee or member insured dies during the period of  active  duty, the conversion right provided by this section shall be available to the surviving spouse and children, and shall  be  available to  a  child  solely  with respect to himself or herself upon his or her attaining the limiting age of coverage under the  group  contract  while covered  as  a dependent thereunder. It shall also be available upon the divorce or annulment of the marriage of the employee or member  insured, to the former spouse of such employee or member insured, if such divorce or annulment occurs during the period of active duty.  (4)  if  the  employee  or  member  insured  elects  the supplementary conversion and continuation right provided for herein or coverage  under the  group  plan  is  suspended,  and such employee or member insured is either reemployed or restored to participation in the group upon  return to  civilian status, he or she shall be entitled to resume participation in insurance offered by the group pursuant  to  this  section,  with  no limitations  or  conditions imposed as a result of such period of active duty except as set forth in subparagraphs (A) and (B) herein. The  right of  resumption  provided  for  herein  shall  extend to coverage for the spouse and dependents of the employee or member insured and shall be  in addition  to other existing rights granted pursuant to state and federal laws and regulations and shall not be deemed to qualify  or  limit  such rights  in  any  way.  No  exclusion or waiting period may be imposed in connection with coverage of a health or physical condition of  a  person entitled  to such right of resumption, or a health or physical condition of any other person who is covered by the policy unless:  (A) the condition arose during the  period  of  active  duty  and  the condition has been determined by the secretary of veterans affairs to be a condition incurred in the line of duty; or  (B)  a  waiting period was imposed and had not been completed prior to the period of suspension; in no event, however, shall  the  sum  of  the waiting  periods  imposed  prior  to  and  subsequent  to  the period of suspension exceed the length of the waiting period originally imposed.  (5) if  the  employee  or  member  insured  elects  the  supplementary conversion and continuation coverage provided for herein:  (A)  when  such  employee  or  member  insured is either reemployed or restored to participation in the group, coverage under the supplementary rights provided for herein shall terminate on the date that coverage  is effective due to resumption of participation in the group.  (B) when such employee or member insured is not reemployed or restored to  participation in the group upon return to civilian status, he or she shall be entitled to the conversion and continuation rights provided  by subsections (d) and (e) of this section.  (i)  To elect an individual conversion contract pursuant to subsection (d) of this section, the employee or member insured must  apply  to  the insurer  within  thirty-one  days  of  the termination of active duty or discharge from hospitalization  incident  to  such  active  duty,  which hospitalization  continues  for a period of not more than one year. Upon commencement of coverage under the conversion right provided pursuant to subsection  (d)  of  this  section,  coverage  under  the  supplementary continuation right provided for herein shall terminate.  (ii)  To  elect continuation of coverage pursuant to subsection (e) of this  section,  the  employee  or  member  insured  must  request   such continuation  of  the employer within thirty-one days of the termination of active duty or discharge from hospitalization incident to such active  duty, which hospitalization continues for a period of not more than  one year.  Upon  commencement  of  coverage  under  the  continuation  right provided pursuant to subsection (e) of this section, coverage under  the supplementary  continuation  right  provided for herein shall terminate. The employee or member insured shall be entitled to have issued  at  the end of the period of continuation an individual conversion contract.  (6) if coverage under the group plan is suspended during the period of active duty:  (A)  when  the  employee or member insured returns to participation in the group plan, coverage under the group plan shall  be  retroactive  to the date of termination of the period of active duty.  (B) when such employee or member insured is not reemployed or restored to  participation in the group upon return to civilian status, he or she shall be entitled to the conversion and continuation rights provided  by subsections (d) and (e) of this section.  (i)  To elect an individual conversion contract pursuant to subsection (d) of this section, the employee or member insured must  apply  to  the insurer  within  thirty-one  days  of  the termination of active duty or discharge from hospitalization  incident  to  such  active  duty,  which hospitalization continues for a period of not more than one year.  (ii)  To  elect continuation of coverage pursuant to subsection (e) of this  section,  the  employee  or  member  insured  must  request   such continuation  of  the employer within thirty-one days of the termination of active duty or discharge from hospitalization incident to such active duty, which hospitalization continues for a period of not more than  one year. The employee or member insured shall be entitled to have issued at the end of the period of continuation an individual conversion contract.  (7)  A  group contract providing hospital, surgical or medical expense insurance for other than accident only shall provide that if all or  any portion  of  the  insurance  on  an employee or member insured under the contract ceases because the employee or member  insured  is  ordered  to active  duty as defined in subsection (h) of this section, such employee or member insured shall be entitled, without evidence  of  insurability, upon  application  to  continue his or her hospital, surgical or medical expense insurance for  himself  or  herself  and  his  or  her  eligible dependents,  under  the supplementary conversion and continuation rights provided for herein, subject to all of  the  group  policy's  terms  and conditions  applicable  to  those forms of benefits and to the following conditions:  (A) continuation shall cease on the date which the employee, member or dependant first becomes, after the date of  election:  (i)  entitled  to coverage  under  title  XVIII  of  the United States Social Security Act (Medicare) as amended or superseded or  (ii)  covered  as  an  employee, member  or dependent by any other insured or uninsured arrangement which provides hospital, surgical or medical coverage  for  individuals  in  a group,  except that the coverage available to active duty members of the uniformed services and their family members shall not  be  considered  a group  under  the  terms  of  this  subsection and except that the group insurance contract conversion  option  of  this  section  shall  not  be considered  as  such  an  arrangement under which an employee, member or dependent could become covered.  (B) an employee or member insured who wishes continuation of  coverage pursuant  to  this  subsection must request such continuation in writing within sixty days of being ordered to active duty.  (C) an employee or member insured electing  continuation  pursuant  to this  subsection  must  pay  to  the group contract holder or his or her employer, but not more frequently than on a monthly  basis  in  advance, the  amount of the required premium payment, but not more than the group  rate for the benefits being continued under the group  contract  on  the due date of each payment.  (8)  The supplementary conversion and continuation rights provided for herein shall apply to:  (A) contracts not covered by Chapter 18  of  the  Employee  Retirement Income  Security Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the Public Health Service Act, 42 U.S.C. section 300bb-1 et seq;  (B) contracts covered by Chapter 18 of the Employee Retirement  Income Security  Act, 29 U.S.C. section 1161 et seq or Chapter 6A of the Public Health Service Act, 42 U.S.C. section 300bb-1 et seq, when  active  duty for  reservists  and  the refusal of an employer to voluntarily maintain coverage for such period of active duty is not considered  a  qualifying event.  (h)  To  be  entitled  to  the right defined in subsection (g) of this section a person must be a member of a reserve component  of  the  armed forces of the United States, including the National Guard, who either:  (1)  voluntarily  or involuntarily enters upon active duty (other than for the purpose of determining his or her  physical  fitness  and  other than for training), or  (2)  has  his or her active duty voluntarily or involuntarily extended during a period when the president is authorized to order units  of  the ready reserve or members of a reserve component to active duty, provided that  such  additional  active  duty  is  at  the  request  and  for the convenience of the federal government, and  (3) serves no more than four years of active duty.  (j)(1) Except as provided in this section, if a  corporation  delivers or  issues  for delivery in this state a group or blanket contract which provides hospital, surgical or medical expense coverage for  other  than accident  only,  the  corporation  must  renew or continue in force such coverage at the option of the contract holder.  (2) A corporation may nonrenew or discontinue coverage  under  such  a group or blanket contract based only on one or more of the following:  (A)  The  contract  holder or a participating entity has failed to pay premiums or contributions in accordance with the terms of  the  contract or the corporation has not received timely premium payments.  (B) The contract holder or a participating entity has performed an act or   practice   that   constitutes   fraud   or   made   an  intentional misrepresentation of material fact under the terms of the contract.  (C) The contract holder has failed to  comply  with  a  material  plan provision  relating  to  employer  contribution  or  group participation rules, as permitted under section four thousand two hundred  thirty-five of this chapter.  (D)  The corporation is ceasing to offer group or blanket contracts in a market in accordance with paragraph three or  paragraph  six  of  this subsection.  (E)  The  contract  holder ceases to meet the requirements for a group under section four thousand two hundred thirty-five of this chapter or a participating employer, labor union, association or other entity  ceases membership  or  participation  in  the  group  to  which the contract is issued. Coverage terminated pursuant to this  paragraph  shall  be  done uniformly without regard to any health status-related factor relating to any covered individual.  (F)  In  the  case  of  a  corporation  that offers a group or blanket contract in a market through a network plan,  there  is  no  longer  any enrollee in connection with such plan who lives, resides or works in the operating  area  of  the  corporation  (or  in  the  area  for which the corporation is authorized to do business).  (G) Such other reasons as are acceptable  to  the  superintendent  and authorized by the Health Insurance Portability and Accountability Act of 1996,  Public  Law  104-191,  and  any  later  amendments  or  successor provisions, or by any federal regulations or rules  that  implement  the provisions of the Act.  (3)  (A)  In  any  case  in which a corporation decides to discontinue offering a particular class of group or blanket  contract  of  hospital, surgical  or  medical  expense  insurance  offered in the small or large group market, the contract of such class  may  be  discontinued  by  the corporation in accordance with this chapter in such market only if:  (i)  the  corporation  provides written notice to each contract holder provided coverage of this class in such market (and to all employees and member insureds covered under such coverage) of such  discontinuance  at least  ninety days prior to the date of discontinuance of such coverage. In addition  to  any  other  information  required  of  notices  by  the superintendent,  this  written  notice  shall  conspicuously  include an explanation, in plain language, of the  contract  holder's  and  covered employee's  or  member  insured's  rights  under  this  subparagraph and subparagraph (B) of this paragraph, including:  (I) a statement that if the superintendent determines that the covered employee,  member  insured,  or  a  dependent  has  a  serious   medical condition,  and the covered employee, member insured or dependent within the previous twelve  months  utilized  a  benefit  under;  the  contrary related  to  the  serious  medical  condition that is not covered by the replacement coverage offered to the contract holder as a result  of  the discontinuance, then the superintendent shall require the corporation to offer  the  contract holder replacement coverage that includes a benefit that is the same as or substantially similar to the benefit set forth in the contract that the corporation discontinued; and  (II) an explanation as to how to contact the superintendent,  and  the date  by  which  the  superintendent shall be contacted, if the contract holder, covered employee or member insured  believes  that  the  covered employee, member insured or a dependent has a serious medical condition, and  the  covered  employee,  member  insured  or  dependent  within the previous twelve months utilized a benefit related to the serious medical condition that may not be covered by the replacement coverage offered to the contract holder as a result of the discontinuance;  (ii) the corporation offers to each contract holder provided  coverage of  this  class  in  such market, the option to purchase all (or, in the case of the large  group  market,  any)  other  hospital,  surgical  and medical expense coverage currently being offered by the corporation to a group in such market;  (iii)  in  exercising the option to discontinue coverage of this class and in  offering  the  option  of  coverage  under  item  (ii)  of  this subparagraph,  the  corporation  acts  uniformly  without  regard to the claims experience of those contract holders or any health status-related factor relating to any particular covered employee,  member  insured  or dependent who may become eligible for such coverage, and the corporation is  not discontinuing the coverage of this class with the intent or as a pretext to discontinuing the  coverage  of  any  such  employee,  member insured or dependent; and  (iv)  at least ninety days prior to the date of discontinuance of such coverage, the corporation provides written notice to the  superintendent of such discontinuance, including the reason for the discontinuance, and an   officer   or   director   of   the  corporation  certifies  to  the superintendent that the corporation has complied with  items  (i),  (ii) and (iii) of this paragraph. If such notice does not include the date or dates  that  the  corporation  mailed  or  delivered  the  notice to all  contract holders, covered employers and member insureds, the corporation shall notify the superintendent of such date within seven  days  of  the completion of the mailing or delivery.  (B)  If  the  superintendent  determines  that the corporation has not complied with item (iii) of subparagraph (A) of this paragraph, then the superintendent may prohibit the corporation from discontinuing the class of contracts and  require  the  corporation  to  promptly  notify  every contract   holder,   covered   employee  and  member  insured  that  the corporation is not discontinuing the contracts.  If  the  superintendent determines  that  the  corporation  wrongfully discontinued the class of contracts  pursuant  to  item  (iii)  of  subparagraph  (A),  then   the superintendent  shall require that the corporation take remedial action, including offering to group contract holders the option  of  reinstating the  discontinued  contract forms. If the superintendent determines that the corporation discontinued the class of contracts  without  compliance with  items  (i),  (ii),  or  (iv) of subparagraph (A), and an employee, member insured or dependent  covered  under  the  discontinued  contract would  have  been  entitled  to  relief  under  this paragraph, then the superintendent  may  require  that  the  corporation  offer  replacement coverage  to  an  affected  contract holder consistent with item (ii) of subparagraph (C) of this paragraph.  (C) (i) If, within forty-five days  after  the  corporation  mails  or delivers  the  written  notice of discontinuance required by item (i) of subparagraph (A) of this paragraph, the superintendent is notified by  a contract  holder  or  covered  employee or member insured that a covered employee, member insured or dependent has a  serious  medical  condition and  that  a benefit utilized by the covered employee, member insured or dependent within the previous  twelve  months  related  to  the  serious medical condition may not be covered by the replacement coverage offered to  the  contract  holder  as  a  result of the discontinuance, then the superintendent shall, within twenty days of the  notification,  ask  the corporation  to  confirm  that  the  covered employee, member insured or dependent utilized a benefit within the previous twelve months to  treat the  medical  condition  that  the  covered  employee, member insured or dependent asserts is a serious medical condition, and that  the  benefit is  not  covered  by  the  replacement  coverage. The superintendent may request such additional information as the superintendent  may  require. The   corporation   shall  provide  all  requested  information  to  the superintendent within five days of receipt of the request.  (ii) If, within twenty days of the  superintendent's  receipt  of  all additional    information    requested   from   the   corporation,   the superintendent determines that (I) the covered employee, member  insured or  dependent  has  a  serious  medical  condition; and (II) the benefit utilized by the covered employee, member insured or dependent within the previous twelve months related to the serious medical condition  is  not covered  by the replacement coverage offered to the contract holder as a result of the discontinuance, then the superintendent shall require  the corporation  to  offer  to the contract holder replacement coverage that includes a benefit that is the same as or substantially similar  to  the benefit  set forth in the contract that the corporation discontinued. If the replacement coverage is not available, at the time that the contract would otherwise be discontinued, then the  corporation  shall  keep  the existing  policy  in  force  for  the affected contract holder until the replacement  coverage  with  the  substantially   similar   benefit   is available.  (D) The remedies as provided in this paragraph shall be in addition to and not in lieu of any other authority or power of the superintendent to impose monetary or other penalties for violations of this paragraph.  (E)  In any case in which a corporation elects to discontinue offering all hospital, surgical and medical expense coverage in the  small  group market or the large group market, or both markets, in this state, health insurance coverage may be discontinued by the corporation only if:  (i)  the corporation provides written notice to the superintendent and to each contract holder (and all employees and member  insureds  covered under  such coverage) of such discontinuance at least one hundred eighty days prior to the date of the discontinuance of such coverage;  (ii) all hospital, surgical and medical  expense  coverage  issued  or delivered  for  issuance  in  this  state  in  such market or markets is discontinued and coverage under such contracts in such market or markets is not renewed; and  (iii) in addition to the notice to the superintendent referred  to  in item  (i)  of  this  subparagraph,  the  corporation  shall  provide the superintendent with a written plan to minimize potential  disruption  in the  marketplace  occasioned  by  the  corporation's withdrawal from the market.  (F) In the case of a discontinuance under  subparagraph  (E)  of  this paragraph  in a market, the corporation may not provide for the issuance of any group or  blanket  contract  of  hospital,  surgical  or  medical expense  insurance  in  that  market  in this state during the five-year period beginning on the date of the discontinuance of  the  last  health insurance contract not so renewed.  (4)  At the time of coverage renewal, an insurer may modify the health insurance coverage for a group or blanket contract offered to a large or small group contract holder so long as such modification  is  consistent with this chapter and effective on a uniform basis among all small group contract holders with that contract.  (5) For purposes of this subsection the term "network plan" shall mean a  health  insurance  contract under which the financing and delivery of health care (including items and services paid for  as  such  care)  are provided,  in whole or in part, through a defined set of providers under contract  either  with  the  corporation  or  another  entity  that  has contracted with the corporation.  (6)  Notwithstanding paragraph three of this subsection, a corporation may discontinue offering a particular class of group or blanket contract of hospital, surgical or medical expense insurance offered in the  small or  large group market, and instead offer a group or blanket contract of hospital, surgical or medical expense insurance that complies  with  the requirements of section 2707 of the public health service act, 42 U.S.C. §  300gg-6  that become applicable to such contract as of January first, two thousand fourteen, provided that the corporation:  (A) discontinues the existing class of contract in such market  as  of either  December  thirty-first,  two  thousand  thirteen or the contract renewal date occurring in two thousand fourteen in accordance with  this chapter;  (B)  provides written notice to each contract holder provided coverage of the class in the market (and to all  employees  and  member  insureds covered  under such coverage) of the discontinuance at least ninety days prior to the date of discontinuance of such coverage. The written notice shall be in a form satisfactory to the superintendent;  (C) offers to each contract holder provided coverage of the  class  in the  market,  the  option  to purchase all (or, in the case of the large group market, any) other hospital, surgical and medical expense coverage that complies with the requirements of section 2707 of the public health service act, 42 U.S.C. § 300gg-6 that become applicable to such coverage as of January first, two thousand fourteen, currently being  offered  by the corporation to a group in that market;  (D)  in exercising the option to discontinue coverage of the class and in offering the option  of  coverage  under  subparagraph  (C)  of  this paragraph,  acts  uniformly  without  regard to the claims experience of those contract holders or any health status-related factor  relating  to any  particular  covered  employee,  member  insured  or  dependent,  or particular new employee, member insured, or  dependent  who  may  become eligible for such coverage, and does not discontinue the coverage of the class  with  the intent or as a pretext to discontinuing the coverage of any such employee, member insured, or dependent; and  (E) at least one  hundred  twenty  days  prior  to  the  date  of  the discontinuance   of  such  coverage,  provides  written  notice  to  the superintendent of the  discontinuance,  including  certification  by  an officer  or  director  of  the  corporation  that  the  reason  for  the discontinuance is  to  replace  the  coverage  with  new  coverage  that complies  with  the  requirements  of  section 2707 of the public health service act, 42 U.S.C. § 300gg-6 that become  effective  January  first, two  thousand  fourteen.  The  written  notice shall be in such form and contain such information the superintendent requires.  (k)(1) No corporation delivering or issuing for delivery in this state a group or blanket contract which provides hospital, surgical or medical expense  coverage  shall  establish  rules  for  eligibility  (including continued  eligibility) of any individual or dependent of the individual to enroll under the contract  based  on  any  of  the  following  health status-related factors:  (A) Health status.  (B) Medical condition (including both physical and mental illnesses).  (C) Claims experience.  (D) Receipt of health care.  (E) Medical history.  (F) Genetic information.  (G) Evidence of insurability (including conditions arising out of acts of domestic violence).  (H) Disability.  (2)  For  purposes  of  paragraph  one  of  this subsection, rules for eligibility include rules defining any applicable  waiting  periods  for such enrollment.  (3)  No  corporation  may,  on  the basis of any health status-related factor in relation to the subscriber or  dependent  of  the  subscriber, require  any  subscriber  (as  a  condition  of  enrollment or continued enrollment under the contract) to pay a premium or contribution which is greater than such premium for a similarly situated  subscriber  enrolled in the plan.  (4)  Nothing in this subsection shall require a corporation to issue a group or blanket contract to a group  comprised  of  fifty-one  or  more lives exclusive of spouses and dependents.  (5)  Where an eligible subscriber or dependent of a subscriber rejects initial  enrollment  in  a  group  or  blanket  contract  that  provides hospital,  surgical  or  medical  expense insurance, a corporation shall permit a subscriber or dependent of a subscriber to enroll for  coverage under  the terms of the contract if each of the following conditions are met:  (A) The subscriber or dependent was  covered  under  another  plan  or contract at the time coverage was initially offered.  (B)(i)  Coverage was provided in accordance with continuation required by federal or state law and was exhausted; or  (ii) Coverage under  the  other  plan  or  contract  was  subsequently terminated  as  a  result  of loss of eligibility for one or more of the following reasons:  (I) termination of employment;  (II) termination of the other plan or contract;  (III) death of the spouse;  (IV) legal separation, divorce or annulment;  (V) reduction in the number of hours of employment; or  (iii)  Contract holder contributions toward the payment of premium for the other plan or contract were terminated.  (C) Coverage must be applied for within thirty days of termination for one of the reasons set forth in subparagraph (B) of this paragraph.  (6) With respect to group or blanket contracts delivered or issued for delivery in this state covering  between  two  and  fifty  employees  or members,  the provisions of this subsection shall in no way diminish the rights of such groups pursuant to section four  thousand  three  hundred seventeen of this article.  (7)  For  purposes  of  this  subsection,  the  term "dependent" shall include a child as described in subsection (c) of this section.  (l)(1) As used in this subsection, "child" means  an  unmarried  child through  age  twenty-nine of an employee or member insured under a group contract of hospital, medical or surgical expense insurance,  regardless of  financial dependence, who is not insured by or eligible for coverage under any employer health benefit plan as an employee or member, whether insured or self-insured, and who lives, works or  resides  in  New  York state  or  the  service  area  of the corporation and who is not covered under title XVIII of the United States Social Security Act (Medicare).  (2) In addition to the conversion privilege afforded by subsection (d) of this section and the continuation privilege  afforded  by  subsection (e)  of  this  section,  a  hospital  service, health service or medical expense corporation or health  maintenance  organization  that  provides group  hospital,  medical or surgical coverage under which coverage of a child terminates at a specified  age  shall,  upon  application  of  the employee,  member  or  child,  as  set forth in subparagraph (B) of this paragraph, provide coverage to the child after that  specified  age  and through age twenty-nine without evidence of insurability, subject to all of the terms and conditions of the group contract and the following:  (A)  An  employer shall not be required to pay all or part of the cost of coverage for a child provided pursuant to this subsection;  (B) An employee, member or child who wishes to elect  continuation  of coverage  pursuant  to this subsection shall request the continuation in writing:  (i) within sixty days following  the  date  coverage  would  otherwise terminate  due  to  reaching  the  specified  age set forth in the group contract;  (ii) within sixty days after meeting the requirements for child status set forth in paragraph one of this  subsection  when  coverage  for  the child previously terminated; or  (iii) during an annual thirty-day open enrollment period, as described in the contract;  (C) An employee, member or child electing continuation as described in this  subsection  shall pay to the group contractholder or employer, but not more frequently than on a monthly basis in advance,  the  amount  of the  required  premium  payment  on  the  due  date of each payment. The written election  of  continuation,  together  with  the  first  premium payment  required  to  establish  premium  payment on a monthly basis in advance, shall be given to the group contractholder or  employer  within the  time  periods  set forth in subparagraph (B) of this paragraph. Any premium received within the thirty-day period after the due  date  shall be considered timely;  (D)  For any child electing coverage within sixty days of the date the child would otherwise lose coverage due to reaching a specified age, the effective date of the continuation coverage shall be the  date  coverage would  have  otherwise  terminated.  For  any  child  electing to resume coverage  during an annual open enrollment period, the effective date of the continuation coverage shall be prospective no later than thirty days after the election and payment of first premium;  (E) Coverage for a child pursuant to this subsection shall consist  of coverage  that  is identical to the coverage provided to the employee or member parent. If coverage is modified under the contract for any  group of similarly situated employees or members, then the coverage shall also be modified in the same manner for any child;  (F) Coverage shall terminate on the first to occur of the following:  (i)  the  date the child no longer meets the requirements of paragraph one of this subsection;  (ii) the end of the period for which premium payments  were  made,  if there  is a failure to make payment of a required premium payment within the period of grace described in subparagraph (C) of this paragraph; or  (iii) the date on which the  group  contract  is  terminated  and  not replaced by coverage under another group contract; and  (G)  The  corporation or health maintenance organization shall provide written notification of the continuation  privilege  described  in  this subsection  and  the time period in which to request continuation to the employee or member:  (i) in each certificate of coverage; and  (ii) at least sixty days prior to termination at the specified age  as provided in the contract.  (3)(A)  Corporations and health maintenance organizations shall submit such reports as may be requested by the superintendent to  evaluate  the effectiveness of coverage pursuant to this subsection including, but not limited to, quarterly enrollment reports.  (B)  The  superintendent  may  promulgate  regulations  to  ensure the orderly  implementation  and  operation  of  the  continuation  coverage provided   pursuant   to   this   subsection,   including  premium  rate adjustments.  (m) A health care claim from a subscriber  covered  under  a  contract issued  pursuant  to  this section shall be submitted within one hundred twenty days from the date of service; provided, however, that if it  was not  reasonably  possible  for the subscriber to submit the claim within that timeframe, then the claim shall be submitted as soon as  reasonably possible.  (n) (1) Any corporation subject to the provisions of this article that issues  hospital,  surgical  or  medical  expense contracts in the small group or large group market in this state shall offer to any employer in this state all such contracts in the applicable market, and shall accept at all times throughout the year any employer that applies  for  any  of those contracts.  (2)  The  requirements of paragraph one of this subsection shall apply with respect to an employer that applies for  coverage  either  directly from  the  corporation  or  through an association or trust to which the corporation has issued coverage and in which the employer participates.