New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 360 - Rules To Assure An Orderly Implementation And Ongoing Operation Of Open Enrollment And Community Rating Of Individual And Small Group Health Insurance › Section 360.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Association
				group means a group defined in section 4235 (c)(1)(B) (D) (H) (K) (L) and (M)  of the Insurance Law, including but not
				limited to an association or trust of employers, if the group includes one or
				more member employers or other member groups which have 50 or fewer employees
				or members exclusive of spouses and dependents. A group containing individual
				members of an association will be considered an association group having member
				groups of 50 or fewer members.
(b)
				Community rated means a rating methodology in which the premium for all persons
				covered by a policy or contract form is the same based on the experience of the
				entire pool of risks covered by that policy or contract form without regard to
				age, sex, health status or occupation. Refunds, rebates, credits or dividends
				based on such factors are also prohibited.
(c) Individual health insurance policy means
				an insurance policy written by an insurer under the provisions of sections 3216, 4304 and
				4501 (o)  of the Insurance
				Law, issued directly to an individual (not on a group or group remittance
				basis), except for policies covering only: long term care benefits, nursing
				home benefits, home care benefits, dental or vision care services, hospital or
				surgical indemnity benefits with specific dollar amounts unless the dollar
				amounts exceed the amounts required to meet the definitions of basic hospital
				and basic medical insurance in sections
				52.5 and
				52.6  of
				this Title, accident only indemnity benefits, accidental death and
				dismemberment benefits, prescription drug benefits, disability income benefits
				or specified disease benefits.
(d)
				Insurer means any commercial insurance company, any fraternal benefit society,
				or any corporation licensed under article 43 of the Insurance Law or article 44
				of the Public Health Law, other than a social health maintenance organization,
				unless otherwise specified in the regulation.
(e) Open enrollment means that any
				individual, and dependents of such individual, and any small group, including
				all eligible employees or group members and dependents of employees or members,
				applying for individual or small group health insurance coverage, including
				Medicare supplement coverage, must be accepted at all times throughout the year
				for any hospital and/or medical coverage offered by the insurer to individuals
				or small groups in this state, and once accepted for coverage, an individual or
				small group cannot be terminated by the insurer due to claims
				experience.
(f) Small group health
				insurance policy means a group remittance policy written by an insurer pursuant
				to section 4304  of the Insurance Law and a group
				health insurance policy covering from two to 50 employees or members, exclusive
				of dependents and spouses, and policies issued to or through association groups
				as defined in subdivision (a) of this section. In determining the size of a
				small group reference should be made to section
				360.4(i)
				and (j)  of this Part. Insurers may choose to
				classify individual proprietors within the small group category provided that
				any such classification is applied consistently to all individual proprietors.
				A small group health insurance policy does not include a policy covering only:
				long term care benefits, nursing home benefits, home care benefits, dental or
				vision care services, hospital or surgical indemnity benefits with specific
				dollar amounts unless the dollar amounts exceed the amounts required to meet
				the definitions of basic hospital and basic medical insurance in sections
				52.5 and
				52.6  of
				this Title, accident only indemnity benefits, accidental death and
				dismemberment benefits, prescription drug benefits, disability income benefits
				or specified disease benefits.