2023 New York Laws › ISC - Insurance › Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations › 4304 - Individual Contracts.

§  4304.  Individual  contracts.  (a) Every corporation subject to the
provisions of this article may issue a contract  to  an  individual  the
premiums  for  which  may  be  paid  to  the corporation directly by the
individual or by a remitting agent for the group to which the individual
belongs. If the premiums for a contract issued pursuant to this  section
are paid to the corporation by a remitting agent, such contract shall be
subject  to subsections (k) and (l) of section four thousand two hundred
thirty-five of this chapter, and for the purposes of these  subsections,
the remitting agent shall be treated as the policyholder.
(b)(1) Any such contract shall be for a period not in excess of twelve
months,  but  no  contract  shall be made providing for the inception of
benefits at a date later than one year from the date of the contract.
(2) Any such contract shall provide  that  it  will  be  automatically
renewed from year to year unless there shall have been one month's prior
written notice of termination by the subscriber.
(3)  No corporation shall refuse to renew any such contract because of
the physical or mental condition or the health  of  any  person  covered
thereunder.  The  provisions of this subsection shall in no way diminish
the rights of  individuals  pursuant  to  section  four  thousand  three
hundred seventeen of this article.
(c) Any such contract may be terminated in the following manner:
(1)  At  the  option of the individual to whom the contract is issued,
upon not less than one month's prior written notice.
(2) At the option of the corporation, for one or more of the following
reasons:
(A) The individual 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 individual has performed an act or practice  that  constitutes
fraud  or  made  an intentional misrepresentation of material fact under
the terms of the contract, upon not less than one month's prior  written
notice.
(C)  (i)  Discontinuance  of  a  class  of contract upon not less than
ninety  days'  prior  written  notice.  In  exercising  the  option   to
discontinue  coverage  pursuant  to  this item, the corporation must act
uniformly without regard to any health status-related factor of enrolled
individuals or individuals who may become eligible for such coverage and
must  offer  to  subscribers  or  group  remitting  agents,  as  may  be
appropriate,   the  option  to  purchase  all  other  individual  health
insurance  coverage  currently  being  offered  by  the  corporation  to
applicants  in  that  market. 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 item through the offering of contracts at each level of coverage as
defined in subsection (b) of section four thousand three  hundred  six-h
of  this  article  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 by another corporation, insurer or
health maintenance organization within the  corporation's  same  holding
company system, as defined in article fifteen of this chapter.
(ii)  Discontinuance  of  all  hospital,  surgical  or medical expense
coverage in the individual direct payment  market  in  this  state  upon
written  notice  to  the  superintendent and to each subscriber not less
than one hundred eighty days prior to the date of the expiration of such
coverage. In the event of such a withdrawal from the  individual  direct
payment  market,  the  corporation  must also provide the superintendent
with a written plan to minimize potential disruption in the  marketplace
occasioned  by  such  withdrawal.  In  addition, the corporation may not

provide for the issuance of any hospital, surgical  or  medical  expense
coverage  in  the  individual direct payment market in this state during
the five-year period beginning on the date of the discontinuance of  the
last health insurance coverage not so renewed.
(iii)  Discontinuance  of all individual hospital, surgical or medical
expense insurance contracts  for  which  the  premiums  are  paid  by  a
remitting  agent  of  a  group,  in the small group market, or the large
group market, or both markets, in this  state,  in  conjunction  with  a
withdrawal  from  the  small group market, or the large group market, or
both markets, in this state. Withdrawal from the small group market,  or
the  large  group  market,  or  both  markets,  shall be governed by the
requirements  of  subparagraphs  (E)  and  (F)  of  paragraph  three  of
subsection  (j)  of  section  four  thousand  three hundred five of this
article. For purposes of this item, "withdrawal"  from  a  market  means
that no coverage is offered or maintained in such market under contracts
issued  pursuant to this section or contracts issued pursuant to section
four thousand three hundred five of this article.
(D) In the case of a corporation that offers health insurance  in  the
market  through  a network plan, the individual no longer resides, lives
or works in the service area (or in an area for which the corporation is
authorized to do business) but only if such coverage is terminated under
this paragraph uniformly without regard  to  any  health  status-related
factor  of  covered  individuals. For the purposes of this subparagraph,
the term "network plan" means health insurance coverage of a corporation
organized under this article 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.
(E) In case of a contract  for  which  the  premiums  are  paid  by  a
remitting   agent   of  a  group,  discontinuance  of  the  individual's
membership in such group.
(F)  Such  other  reasons  as  the  superintendent  may  approve   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,  upon  not less than one month's prior written
notice.
(3) Every notice of termination shall be in a form satisfactory to the
superintendent  and  shall  include  a  statement  of   the   conversion
privileges, if any, upon such termination.
(4)  In  the event of termination of a contract, the corporation shall
return the unearned portion of the premium.
(d) (1) (A) No contract issued pursuant to this section shall  entitle
more  than  one  person  to  benefits  except that a contract issued and
marked as  a  "family  contract"  may  provide  that  benefits  will  be
furnished  to  the contract holder, spouse, dependent child or children,
or other person chiefly dependent  upon  the  contract  holder  provided
that:
(i)  A "family contract" may provide coverage to any child or children
not over nineteen years of age, provided that an unmarried student at an
accredited institution of learning may be considered a  dependent  until
the  child becomes twenty-three years of age, and provided also that the
coverage of any such "family contract" may include, at the option of the
corporation,  any  unmarried  child  until  attaining  age  twenty-five.
However,   a  "family  contract"  of  hospital,  medical,  surgical,  or
prescription drug expense insurance that provides coverage for dependent
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  contract  holder,  student  status,  or
employment.
(ii)  The  coverage  of  any  such "family contract" shall include any
other  unmarried  child,  regardless  of  age,  who  is   incapable   of
self-sustaining  employment  by  reason of mental illness, developmental
disability, 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.
(B) In addition to  the  requirements  of  subparagraph  (A)  of  this
paragraph,  every corporation issuing a contract of hospital, medical or
surgical expense insurance that provides coverage for children must make
available and if requested by the contractholder, extend coverage  under
the  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 for
group remittance 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 contract,  and  for  group
remittance contracts annually thereafter.
(C)  Notwithstanding  any rule, regulation or law to the contrary, any
"family contract"  shall  provide  that  coverage  of  newborn  infants,
including   newly  born  infants  adopted  by  the  subscriber  if  such
subscriber 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
contract 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  remitting  agent's
plan does not provide coverage for children.
(2) Every "family contract" under which coverage of a dependent spouse
or  contract  holder would terminate upon such spouse or contract holder
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 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 mailed by the corporation to the last known address  of  the
such spouse or contract holder.
(3)  Coverage  of  an  unmarried  dependent  child who is incapable of
self-sustaining employment by reason of  mental  illness,  developmental
disability,  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 the
contract  holder  for support and maintenance, shall not terminate while
the contract remains in force and the child remains in  such  condition,
if  the  contract  holder  has  within  thirty-one  days of such child's
attainment  of  the  limiting  age  submitted  proof  of  such   child's
incapacity as described herein.
(e)  (1) (A) If any such contract is terminated in accordance with the
provisions of paragraph one of subsection (c) of this  section,  or  any
such  contract is terminated because of a default by the remitting agent
in the payment of premiums not cured within the  grace  period  and  the
remitting   agent  has  not  replaced  the  contract  with  similar  and
continuous coverage for the same group whether insured or  self-insured,
or  any such contract is terminated in accordance with the provisions of
subparagraph (E) of paragraph two of subsection (c) of this section,  or
if  an  individual  other  than the contract holder is no longer covered
under a "family contract" because the individual is no longer within the
definition set forth in the contract, or a spouse is no  longer  covered
under  the  contract  because  of  divorce  from  the contract holder or
annulment of the marriage, or any such contract is terminated because of
the death of the contract holder, then such individual,  former  spouse,
or  in the case of the death of the contract holder the surviving spouse
or other dependents of the deceased contract holder  covered  under  the
contract,  as  the  case  may  be, shall be entitled to convert, without
evidence of insurability, upon application therefor and  the  making  of
the  first  payment  thereunder  within  sixty  days  after  the date of
termination of such contract, to a contract 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.
(B) 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  individual  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  paragraph  through the offering of contracts that comply with this
paragraph  by  another  corporation,  insurer  or   health   maintenance
organization  within  the  corporation's same holding company system, as
defined in article fifteen of this chapter.
(C) The effective date of  the  coverage  provided  by  the  converted
direct payment contract shall be the date of the termination of coverage
under the contract from which conversion was made.
(2)  The corporation shall not be required to issue any such converted
individual direct payment contract  if  its  issuance  would  result  in
overinsurance  or duplication of benefits according to standards on file
with the superintendent and approved by the superintendent  with  regard
to such contracts.
(3)  In  addition  to  the right of conversion herein, the employee or
member insured under a contract for which the premiums  are  paid  by  a
remitting  agent  of  a  group shall at his option, as an alternative to
conversion, be entitled to have his coverage continued under  the  group
remittance  contract  in  accordance with the conditions and limitations
contained in subsection (k) of this section, and have issued at the  end

of  the  period  of continuation an individual direct payment conversion
contract subject to the terms of this subsection. The effective date for
the conversion contract shall be the day following  the  termination  of
insurance  under  the  group  remittance  contract,  or  if  there  is a
continuation of coverage, on the day following the end of the period  of
continuation.
(4)  For  purposes  of  this  subsection,  the  term "dependent" shall
include a child as described in subsection (d) of this section.
(f) No such corporation shall require as a condition  for  renewal  or
for  failure to cancel any individual contract any rider, endorsement or
other attachment which shall limit the nature or extent of the  benefits
thereunder,  except  that  a  corporation  may at any time upon at least
thirty days' prior written notice  amend  such  contract  to  provide  a
different level of benefits thereunder if approved by the superintendent
on  finding,  upon  application  by the corporation at least four months
before the proposed effective date, that such level would exceed, in the
aggregate, the level of benefits theretofore provided and  would  be  in
the best interests of the corporation and the persons covered under such
contracts.
(g)  The provisions of this section with respect to limitations on the
termination of an individual contract shall not apply to a  contract  or
an endorsement or rider thereto which is issued by a corporation subject
to  the  provisions  of  this  article  pursuant to a plan providing for
experimentation in  new  forms  of  benefits  in  the  field  of  health
insurance  protection,  which  plan shall be submitted in writing to the
superintendent. The superintendent shall approve such plan if  he  finds
that  the  benefits  are  of  the type heretofore described and that the
issuance of such  contract,  endorsement  or  rider  is  in  the  public
interest.  Approval  of  such  contract,  rider  or endorsement shall be
subject to any conditions which may be prescribed by the superintendent,
including, but not limited to,  the  maximum  period  during  which  the
exemption   from   the  provisions  of  this  section  with  respect  to
termination shall continue.  The  superintendent  may,  for  good  cause
shown,  extend  such  period  of  exemption.  Any  termination  of  such
contract, rider or endorsement during the  period  of  exemption,  other
than  for non-payment of premium and fraud in applying for the contract,
shall be subject to the approval of the superintendent. Upon termination
of such contract, or termination of a  rider  or  endorsement  providing
experimental  benefits, as aforesaid, the contract holder thereunder who
has  at  the  time  of  such  termination  been   covered   continuously
immediately preceding such termination for a period of two years or more
under one or more contracts of the corporation shall be entitled to have
issued to him by the corporation, without evidence of insurability, upon
application  therefor  and  the  making  of the first payment thereunder
within thirty-one days after the  date  of  termination,  an  individual
direct  payment  contract of the type and class which the superintendent
shall determine  provides  benefits  most  nearly  comparable  to  those
currently  provided  other  individuals.  If  the  corporation  does not
terminate such contract or a  rider  or  endorsement  thereto  providing
experimental  benefits  as  aforesaid during the period of exemption, or
any extended period provided herein, such contract shall  thereafter  be
subject to the provisions of this section with respect to termination as
of the original effective date of such contract.
(h)  Any  contract,  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 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."
(i)  Any  persons  covered  by  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, upon written request, to have
their coverage suspended during a period of  active  duty  as  described
herein.  The  contract  shall  provide  that the insurer will refund any
unearned premiums for the period of such suspension. Persons covered  by
the  contract  shall be entitled to resumption of coverage, upon written
application and payment of the required premium within sixty days  after
the  date  of  termination  of  the  period  of  active  duty,  with  no
limitations or conditions imposed as a result of such period  of  active
duty  except  as  set  forth  in paragraphs one and two herein. Coverage
shall be retroactive to the date of termination of the period of  active
duty.  Such right of resumption provided for herein 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 contract unless:
(1) 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
(2)  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.
(j) To be entitled to the right defined  in  subsection  (i)  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.
(k) A contract for which the premiums are paid by a remitting agent of
a  group 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 contract ceases
because of termination of employment  or  membership  in  the  class  or
classes  eligible  for  coverage  under  the  contract, such employee or
member  shall  be  entitled  without  evidence  of   insurability   upon
application  to continue his or her insurance for himself or herself and
his or her eligible dependents, subject to all of the  group  remittance
contract's  terms  and  conditions applicable to those forms of benefits
and to the following conditions:
(1) Continuation shall not be available for: (A)  any  person  who  is
covered,  becomes  covered  or  could  be  covered by title XVIII of the
United States Social Security Act (Medicare) as amended  or  superseded;
or  (B) an employee, member or dependent who is covered, becomes covered

or could become 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, except the group insurance or  group
remittance  contract  conversion  option  of  this  section shall not be
considered as such an arrangement under which  an  employee,  member  or
dependent could become covered.
(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 given notice of the right of continuation by either
his employer or the group remitting agent.
(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  remitting  agent  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
remitting agent 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 remittance 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  group remitting agent 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  remittance  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  remittance  contract  with  that
remitting  agent  is terminated or, in the case of an employee, the date
his  employer  terminates  participation  under  the  group   remittance
contract.    However, if this clause applies and the coverage ceasing by
reason of such termination is replaced by similar coverage under another
group or group remittance contract, the following shall apply:
(i) The employee or member shall have  the  right  to  become  covered
under  that other group or group remittance contract, for the balance of
the period that he would have remained covered  under  the  prior  group

remittance   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
or group remittance contract shall be the applicable level  of  benefits
of  the  prior group remittance contract reduced by any benefits payable
under that prior group remittance contract, and
(iii) The prior group remittance contract shall  continue  to  provide
benefits  to  the  extent  of  its  accrued liabilities and extension of
benefits as if the replacement had not occurred.
(5)(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.
(6) A contract for which premiums are paid by a remitting agent for  a
group  issued  by  a hospital service, health service or medical expense
indemnity  corporation  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.
(7)  For  purposes  of  this  subsection,  the  term "dependent" shall
include a child as described in subsection (d) of this section.
(l) A corporation shall not offer  individual  hospital,  medical,  or
surgical  expense  insurance  contracts  unless  the  contracts meet the
requirements of subsection (b) of section four  thousand  three  hundred
twenty-eight of this article. Such contracts that are offered within the
health  benefit  exchange  established by this state also shall meet any
requirements established by the health benefit exchange. To  the  extent
that  a  holder  of  a  special  purpose certificate of authority issued
pursuant to section four thousand four hundred  three-a  of  the  public
health  law  offers  individual  hospital,  medical, or surgical expense
insurance contracts,  the  contracts  shall  meet  the  requirements  of

subsection  (b)  of  section four thousand three hundred twenty-eight of
this article.
(m)  (1)  As used in this subsection, "child" means an unmarried child
through age twenty-nine of an employee or member insured under  a  group
remittance  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 (e)
of this section and the continuation privilege afforded  by  subsections
(e)  and  (k)  of  this  section,  a hospital service, health service or
medical expense corporation  or  health  maintenance  organization  that
provides  hospital,  medical  or surgical expense insurance coverage for
which the premiums are paid by the  remitting  agent  of  a  group  that
provides  coverage  of a child that 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
remittance 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 remitting agent 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 remitting agent 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 remittance  contract  is  terminated
and  not  replaced  by  coverage under another group or group remittance
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.