reglab/statecodes huggingface dataset:
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 361 - Establishment And Operation Of Market Stabilization Mechanisms For Individual And Small Group Health Insurance And Medicare Supplement Insurance › Section 361.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Part, the following words and phrases are
				  defined as follows:
(a) Article 43
				corporation means a corporation organized under article 43 of the Insurance
				Law.
(b) Average demographic factor
				means the weighted average demographic index of each carrier. The index for a
				particular carrier reflects the expected relative costs for that carrier, based
				only upon the demographic factors of the persons it covers, compared to the
				expected average costs of all carriers, based only upon the demographic factors
				of all persons covered by all carriers.
(c) Carrier 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.
(d) Carrier
				participating in a pool means, with respect to a pool for a particular area, a
				carrier which has in force one or more pooled individual health insurance
				policies covering individuals residing in the pool area, or which has in force
				one or more pooled small group insurance policies covering small groups located
				in the pool area. With respect to small groups, all members of the group shall
				be considered to be located in the same pool area as the group itself,
				regardless of the location of the residences of the members.
(e) Demographic pooling fund means, with
				respect to a particular demographic pool, a fund which is equal to paragraph
				(1) plus paragraph (2), minus paragraph (3), minus paragraph (4) of this
				subdivision:
(1) amounts paid to the fund by
				carriers participating in the pool, as stated in section
				361.3(e)
				and (h)  of this Part;
(2) investment income on the fund;
(3) amounts paid from the fund to carriers
				participating in the pool, as stated in section
				361.3(f)
				and (h)  of this Part; and
(4) amounts paid from the fund to the
				administrator for administration of the fund, as stated in section
				361.6(a)(3)
				and (6)  of this Part.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 361 - Establishment And Operation Of Market Stabilization Mechanisms For Individual And Small Group Health Insurance And Medicare Supplement Insurance › Section 361.3 - Pooling of variations in costs attributable to variations in demographics

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In each pool
				area, two demographic pools are established. Each pool operates independently;
				that is, all calculations and payments described below are made for each pool
				independently of any other pool.
(b) In each pool area:
(1) one pool, for use until December 31,
				1999, deals with individual health insurance policies and small group health
				insurance policies, other than Medicare supplement insurance policies;
				and
(2) one pool deals with
				Medicare supplement insurance policies.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 361 - Establishment And Operation Of Market Stabilization Mechanisms For Individual And Small Group Health Insurance And Medicare Supplement Insurance › Section 361.4 - Pooling of the cost of treating specified medical conditions prior to January 1, 1999

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In each
				pool area, a specified medical condition pooling fund is established. Each pool
				operates independently; that is, all calculations and payments described below
				are made for each pool independently of any other pool.
(b) Each carrier shall pay to the pooling
				fund each quarter, beginning with the second quarter of 1993, and ending
				December 31, 1998, an amount determined as the product of paragraphs (1), (2),
				and (3) of this subdivision:
(1) An amount
				determined by the superintendent each year by September 1st, with respect to
				payments required during the subsequent calendar year. For 1993, this amount
				will be $5.
(2) The number of
				family units with coverage of a single individual under a pooled insurance
				contract or policy, other than a Medicare supplement insurance policy, as of
				the beginning of the quarter, plus twice the number of family units with
				dependents coverage by the carrier under a pooled insurance contract or policy,
				other than a Medicare supplement insurance policy, as of the beginning of the
				quarter.
(3) A coverage factor, as
				follows:
Type of Contract
Coverage Factor
Basic Hospital or Basic Hospital/Surgical
0.75
Wraparound or Supplemental Major Medical
0.25
Basic and Supplemental Major Medical, Comprehensive
							 Major Medical, HMO
1.0
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 361 - Establishment And Operation Of Market Stabilization Mechanisms For Individual And Small Group Health Insurance And Medicare Supplement Insurance › Section 361.6 - Pooling of variations of costs attributable to high cost claims beginning in 2006 through 2013 for individual and small group policies, other than Medicare supplement and Healthy New York policies

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In each pool area a risk adjustment pool
				is established in connection with individual and small group health insurance
				policies, other than Medicare supplement insurance policies and Healthy New
				York health insurance policies. Each pool shall operate independently; that is,
				all calculations and payments described below are made for each pool
				independently of any other pool.
(b) The annual funding amount for all pool
				areas combined is as follows:
(1) $80,000,000
				for 2007;
(2) $120,000,000 for
				2008; and
(3) $160,000,000 for 2009
				and each calendar year thereafter.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 361 - Establishment And Operation Of Market Stabilization Mechanisms For Individual And Small Group Health Insurance And Medicare Supplement Insurance › Section 361.7 - Pool administration

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				The pools shall be administered either directly by the superintendent, or in
				conjunction with a firm, performing at least the following functions:
(1) choosing a firm or firms, other than a
				carrier participating in any of the pools, to administer the pools, based on an
				evaluation of competitive bids;
(2)
				approval of the general systems and procedures used by the firm or firms to
				administer the pools, including in particular procedures to verify the
				appropriateness of payments from the pools to carriers;
(3) payment of reasonable fees from the
				pooling funds to the firm or firms for administration of the pools;
(4) changing the administrating firm or
				firms, or the administrative systems and procedures, if necessary;
(5) the collection from pool participants of
				the data needed to administer the pools;
(6) the arrangement for periodic audits of
				the pools, including the participation of each carrier, and paying from the
				pooling funds reasonable fees for such audits;
(7) the reporting to the carriers
				participating in the pools a summary of the operations of the pools, on a
				periodic basis, but in no event less often than annually; and
(8) establishing equitable assessments on
				carriers participating in the pools as needed to make the payments from the
				pools stated in paragraphs (3) and (6) of this subdivision, in sections
				361.3(f),
				361.4(c)
				and (d) and
				361.5(d) 
				of this Part.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 361 - Establishment And Operation Of Market Stabilization Mechanisms For Individual And Small Group Health Insurance And Medicare Supplement Insurance › Section 361.8 - Review of pool operations

Current through Register Vol. 46, No. 28, July 10, 2024
Commencing on January 1, 1994, the superintendent shall
				  review the operation of the pooling process described in this Part to determine
				  whether the process is serving the purposes described in section
				  361.1  of this
				  Part. The carriers participating in the pools shall cooperate with the
				  superintendent in providing information necessary to properly evaluate the
				  process, and the superintendent shall seek and accept additional information
				  from the Technical Advisory Committee. On or before July 1, 1994, the
				  superintendent shall prepare a report that analyzes whether and how well the
				  pooling mechanism is fulfilling its intended purposes, and if appropriate,
				  shall make changes to this Part.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 361 - Establishment And Operation Of Market Stabilization Mechanisms For Individual And Small Group Health Insurance And Medicare Supplement Insurance › Section 361.10 - Market stabilization pools for the individual and small group health insurance markets for plan years 2018 and thereafter

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
(1)
				This section applies to risk adjustment experience in the individual and small
				group health insurance markets for plan years 2018 and thereafter.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-2 - Rules Generally Applicable To The Healthy New York Program › Section 362-2.1 - Definitions generally applicable to the healthy new york program

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Health
				  insurance shall mean any coverage (whether insured or self-insured) providing
				  both hospital and medical benefits on an expense-incurred or prepaid basis or
				  any coverage providing hospital and medical indemnity benefits with specific
				  dollar amounts if the dollar amounts exceed the amounts required to meet the
				  definitions of basic hospital and basic medical insurance set forth in sections
				  52.5 and
				  52.6  of
				  this Title. Health insurance shall not include health benefits offered through
				  public benefit programs. Health insurance also shall not include coverage
				  established by the continuation provisions of the Employee Retirement Income
				  Security Act,
				  29
				  U.S.C. section 1161 et seq. and the Public
				  Health Service Act,
				  42
				  U.S.C. section 300bb-1 et seq. established by
				  the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, or the
				  continuation provisions of the New York State Insurance Law, sections 3221(m),
				  4304(k) and 4305(e).
(b) Health
				  maintenance organization shall mean an organization (or line of business of an
				  article 43 corporation) which has received a certificate of authority to
				  operate as a health maintenance organization from the Commissioner of Health
				  pursuant to article 44 of the Public Health Law.
(c) Insurer shall mean a corporation
				  organized under article 43 of the Insurance Law or an organization licensed or
				  organized under article 42 of the Insurance Law.
(d) Participating insurer means an insurer
				  which voluntarily participates in the Healthy New York Program in accordance
				  with section 4326 (b)  of the Insurance
				  Law.
(e) Qualifying group health
				  insurance contract means a group contract or group remittance contract issued
				  to a qualifying small employer pursuant to section 4326 (c)(2)  of the
				  Insurance Law.
(f) Qualifying
				  health insurance contract shall mean a qualifying group health insurance
				  contract or a qualifying individual health insurance contract.
(g) Qualifying individual health insurance
				  contract means a contract issued directly to a qualifying individual pursuant
				  to section 4326 (c)(4)  of the
				  Insurance Law.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-2 - Rules Generally Applicable To The Healthy New York Program › Section 362-2.2 - Voluntary insurer participation

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Insurers intending to offer qualifying
				  health insurance contracts shall file a statement of such intent with the
				  superintendent. Such statement shall include a description of the counties
				  within which the insurer will offer qualifying health insurance contracts. This
				  statement of intent must be submitted in conjunction with the complete policy
				  form and rate filings at least 90 days prior to the date the insurer intends to
				  commence accepting applications for the Healthy New York Program.
(b) Insurers choosing to participate in the
				  program must do so under the same terms and conditions as are applicable to
				  health maintenance organizations.
(c) Participating insurers must offer both
				  qualifying group health insurance contracts and qualifying individual health
				  insurance contracts.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-2 - Rules Generally Applicable To The Healthy New York Program › Section 362-2.4 - Transfer from other programs

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				  Transferable coverage shall mean coverage issued pursuant to:
(1) the New York State Small Business Health
				  Insurance Partnership Program, established by section 922  of the Public Health Law;
(2) the Voucher Insurance Program,
				  established by section 1121  of the Insurance Law; and
(3) the uninsured pilot programs, established
				  by chapter 703 of the Laws of 1988.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-2 - Rules Generally Applicable To The Healthy New York Program › Section 362-2.5 - Annual recertification of eligibility

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Health maintenance organizations and
				  participating insurers shall, at least 90 days prior to the annual renewal
				  date, provide any forms necessary for recertification.
(b) Health maintenance organizations and
				  participating insurers shall annually collect certifications of continued
				  eligibility for the Healthy New York Program and shall be responsible for
				  examination of such certifications to verify that small employers and
				  individuals participating in the program continue to meet eligibility
				  requirements and continue to comply with the terms of the program. Health
				  maintenance organizations and participating insurers shall determine whether
				  the small employer and individual participants continue to meet the
				  requirements for participation in the Healthy New York Program and shall
				  provide written notice of such determination within two weeks of receipt of the
				  annual recertification.
(c) The
				  failure of an employer or individual to provide written certification
				  demonstrating continued eligibility and continued compliance with the terms of
				  the Healthy New York Program shall be a basis for nonrenewal of a qualifying
				  health insurance contract.
(d)
				  Health maintenance organizations and participating insurers shall provide no
				  less than 45 days written notice to the contract holder and any covered
				  employees of a nonrenewal. Such notice of nonrenewal or termination shall set
				  forth the basis for the nonrenewal and include a description of any applicable
				  conversion rights. Such notice shall also include a description of other
				  coverage options available for purchase from the health maintenance
				  organization or participating insurer.
(e) Healthy New York Program enrollees who
				  have transferred into the program from other public programs pursuant to
				  section 4326 (p)  of the Insurance
				  Law shall not be required to demonstrate satisfaction of the eligibility
				  requirements set forth in section 4326 (c)  of the Insurance
				  Law at the time of annual recertification.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-2 - Rules Generally Applicable To The Healthy New York Program › Section 362-2.6 - Health plan contact information

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Health maintenance organizations and
				  participating insurers shall submit to the superintendent:
(1) the name, address and telephone number of
				  a health plan contact person assigned to the Healthy New York
				  Program;
(2) the address and
				  toll-free telephone number to direct consumer inquiries regarding the Healthy
				  New York Program; and
(3) the
				  service area in which the Healthy New York Program will be available. Any
				  revisions or updates to such information shall be submitted to the
				  superintendent.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-2 - Rules Generally Applicable To The Healthy New York Program › Section 362-2.7 - Healthy new york benefit adjustments

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Beginning June 1, 2003, there shall be no
				  copayment applied to preventive and primary health care services for routine
				  well child visits and necessary immunizations.
(b) Beginning June 1, 2003, health plans
				  shall offer an additional Healthy New York benefit package at a reduced premium
				  rate. Such additional benefit package shall contain all of the benefits set
				  forth in section 4326 (d)(1) through (13)  of
				  the Insurance Law. The prescription drug benefit set forth in section
				  4326(d)(14) shall not be included in the additional benefit package. Qualifying
				  small employers and qualifying individuals shall have the option of choosing
				  among the benefit packages. Qualifying small employers must elect to provide
				  the same benefit package to all of their employees participating in Healthy New
				  York. Once enrolled in the program, any change in the selection of benefit
				  package may occur at the time of annual recertification or at anytime the
				  premium rate changes. Notice of this option shall be included with any notice
				  of rate change.
(c) Individuals who
				  are eligible for a Federal tax credit under the Federal Trade Adjustment Act of
				  2002, who have three months or more of creditable coverage shall be deemed to
				  have sufficient creditable coverage to satisfy the 12-month pre-existing
				  condition waiting period in full.
(d) Beginning January 1, 2007, qualifying
				  health insurance contracts shall include a benefit for up to 40 post-hospital
				  or post-surgical home health care visits per calendar year.
(e) Beginning January 1, 2007, qualifying
				  health insurance contracts shall include a benefit for up to 30 post-hospital
				  or post-surgical physical therapy visits per calendar year.
(f) Beginning January 1, 2007, qualifying
				  health insurance contracts shall include a benefit for diagnostic screening for
				  prostatic cancer consistent with the benefit set forth in section 4303(z-1) of
				  the Insurance Law.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-2 - Rules Generally Applicable To The Healthy New York Program › Section 362-2.8 - High deductible health plan under the healthy new york program

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For purposes of this section:
(1) High deductible health plan shall mean a qualifying health insurance contract with a plan year deductible of at least $1,150 for individual coverage and $2,300 for family coverage. Out-of-pocket expenses, including the deductible and copayments, shall be capped at $5,250 for individual coverage and $10,500 for family coverage for the plan year.
(2) Family coverage means any coverage that is not self-only.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-2 - Rules Generally Applicable To The Healthy New York Program › Section 362-2.9 - Healthy new york enrollment limitation

Current through Register Vol. 46, No. 28, July 10, 2024
(a) With respect to coverage effective on or
				  after January 1, 2012, a health maintenance organization or a participating
				  insurer may enroll new applicants in the Healthy New York Program only in the
				  high deductible health plans set forth in section
				  362-2.8 
				  of this Subpart.
(b) With respect
				  to existing enrollees who are in non-high deductible health plans with coverage
				  effective prior to January 1, 2012, a health maintenance organization or a
				  participating insurer shall:
(1) permit
				  qualifying individuals to add dependents to or remove dependents from their
				  qualifying health insurance contracts; and
(2) permit qualifying small employers to add
				  employees and dependents to or remove employees and dependents from their
				  qualifying health insurance contracts.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-3 - Rules Relating To Small Employer Participation (other Than Individual Proprietors) › Section 362-3.1 - Definitions applicable to small employers (other than individual proprietors)

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				  Employee shall mean any person employed 20 or more hours weekly by a qualifying
				  small employer.
(b) Eligible
				  employee shall mean any employee earning $30,000 or less (adjusted annually as
				  per section
				  4326[c][1][F] of the
				  Insurance Law) in annual wages and any other person as determined by the
				  employer based upon one or more of the following criteria: geographic situs of
				  employment, earnings, method of compensation, hours and occupational
				  duties.
(c) Part-time worker shall
				  mean any person employed less than 20 hours weekly by a qualifying small
				  employer.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-4 - Rules Relating To Working Uninsured Individuals And Individual Proprietor Participation › Section 362-4.1 - Definitions applicable to working uninsured individuals and individual proprietors

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				  Employed person shall mean, for purposes of determining eligibility for
				  qualifying individual health insurance contracts, any person employed on a
				  full-time or part-time basis either currently or within the past 12 months for
				  which monetary compensation was received.
(b) Individual proprietor shall mean an
				  individual proprietor who is the sole owner and employee of a business and
				  shall include, but not be limited to, independent contractors and other
				  self-employed persons.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-4 - Rules Relating To Working Uninsured Individuals And Individual Proprietor Participation › Section 362-4.3 - Verification of net household income

Current through Register Vol. 46, No. 28, July 10, 2024
(a) To qualify for coverage under the Healthy
				  New York Program, individual proprietors and working uninsured individuals must
				  satisfy the household income criteria set forth in section 4326 (c)(1)(A)(ii) and (3)(A)(iii)  of the Insurance Law. For the
				  purpose of determining household income eligibility, household members shall
				  include the applicant, the applicant's legal spouse if residing in the
				  household and any children eligible for coverage under the policy. Income
				  received by the applicant and the applicant's legal spouse residing in the
				  household shall be counted.
(b)
				  Income shall include, but shall not be limited to, the following:
(1) monetary compensation for services
				  including wages, salary, commissions, overtime compensation, fees or
				  tips;
(2) net income from farm and
				  nonfarm self-employment;
(3) social
				  security payments or benefits;
(4)
				  dividends, interest on savings or bonds, regular income from estates or trusts,
				  or net rental income;
(5)
				  unemployment compensation;
(6)
				  government, civilian employee or military retirement or pension or veteran's
				  payments;
(7) private pension or
				  annuity;
(8) alimony;
(9) regular contributions from persons not
				  living in the household;
(10) net
				  royalties; and
(11) such other
				  income as determined by the superintendent.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-5 - Rules Relating To The Direct Payment Market Stop Loss Relief Program And State Funded Stop Loss Relief For The Healthy New York Program › Section 362-5.1 - Definitions applicable to the direct payment market stop loss relief program and state funded stop loss relief for the healthy new york program

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Capitation
				  payments means contractually based prepayments made to a health care provider,
				  on a per member per month or a percentage of premium basis, in exchange for
				  health care services to be rendered, referred or otherwise arranged by such
				  provider.
(b) Claims corridor
				  means:
(1) for the direct payment stop loss
				  fund and the direct payment out-of-plan stop loss fund, claims paid on behalf
				  of a covered member in a given calendar year in excess of $20,000 and less than
				  $100,000;
(2) for calendar years
				  2001 and 2002, for the small employer stop loss fund and the qualifying
				  individual stop loss fund, claims paid on behalf of a covered member in a given
				  calendar year in excess of $30,000 and less than $100,000;
(3) beginning in calendar year 2003, for the
				  small employer stop loss fund and the qualifying individual stop loss fund,
				  claims paid on behalf of a covered member in excess of $5,000 and less than
				  $75,000.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-5 - Rules Relating To The Direct Payment Market Stop Loss Relief Program And State Funded Stop Loss Relief For The Healthy New York Program › Section 362-5.3 - Rating of products eligible for claims reimbursements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The premium rates established for
				  individual enrollee direct payment contracts, individual enrollee out-of-plan
				  direct payment contracts, qualifying group health insurance contracts and
				  qualifying individual health insurance contracts must recognize the
				  availability of reimbursement from the applicable stop loss fund.
(b) Reimbursement from the applicable stop
				  loss fund shall reduce claims expenses for the purposes of calculating loss
				  ratios, premium rates and premium rate adjustments and for the purposes of
				  determining compliance with section 4308  of the Insurance Law and sections
				  52.40
				  through
				  52.45 
				  of this Title.
(c) Initial rate
				  submissions and rate adjustment applications submitted for individual enrollee
				  direct payment contracts, individual enrollee out-of-plan direct payment
				  contracts, qualifying group health insurance contracts and qualifying
				  individual health insurance contracts shall contain such information as may be
				  needed in order to assist the superintendent in determining the anticipated
				  premium rate impact of the availability of reimbursement from the stop loss
				  funds.
(d) Estimates of anticipated
				  receipts from the stop loss funds may be calculated based upon available
				  enrollment data and such other data as may be deemed appropriate by the
				  superintendent.
(e) Healthy New
				  York qualifying group health insurance contracts and qualifying individual
				  health insurance contracts shall be treated as individual products for the
				  purpose of applying loss ratio standards.
(f) Health maintenance organizations and
				  participating insurers may reinsure their Healthy New York business in whole or
				  in part if they determine it would favorably impact premium rates. The impact
				  of any such reinsurance shall be factored into the premium rates for affected
				  qualifying group health insurance premiums and individual health insurance
				  premiums.
(g) No later than 30 days
				  from the effective date of this regulation, health maintenance organizations
				  and participating insurers shall submit the policy form amendments and premium
				  rate adjustments necessitated by these amendments.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-5 - Rules Relating To The Direct Payment Market Stop Loss Relief Program And State Funded Stop Loss Relief For The Healthy New York Program › Section 362-5.4 - Stop loss fund administration

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				  The superintendent shall establish the funds and oversee fund administration.
				  The functions of the superintendent in this regard may include, but shall not
				  be limited to, the following:
(1) choosing a
				  firm or firms, other than a carrier participating in the funds, to administer
				  the funds, based on an evaluation of competitive bids;
(2) granting approval of the general systems
				  and procedures used by the firm or firms to administer the funds, including in
				  particular the procedures utilized to verify the appropriateness of payments
				  from the funds to the health maintenance organizations or participating
				  insurers;
(3) making payment of
				  reasonable fees from the funds to the firm or firms for administration of the
				  funds;
(4) changing the
				  administrating firm or firms, or the administrative systems and procedures, if
				  necessary;
(5) collecting necessary
				  data from health maintenance organizations and participating
				  insurers;
(6) arranging for
				  periodic audits of health maintenance organizations and participating insurers
				  and for the payment of reasonable fees for such audits from the funds;
				  and
(7) granting approval of the
				  format and content of the administrating firm or firms annual report regarding
				  the affairs and operation of the funds, and such other reports as deemed
				  necessary by the superintendent.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-5 - Rules Relating To The Direct Payment Market Stop Loss Relief Program And State Funded Stop Loss Relief For The Healthy New York Program › Section 362-5.5 - Data filing requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				  The superintendent shall require the submission of necessary claims data in
				  connection with each health maintenance organization's and participating
				  insurer's annual submission of requests for reimbursement from the stop loss
				  funds. Each health maintenance organization and participating insurer shall
				  also provide the superintendent with such additional data, as he deems
				  necessary, to oversee the operation of the stop loss funds and the Healthy New
				  York Program. Reports pertaining to stop loss reimbursement or loss ratio shall
				  be certified by an officer of the company that such report is accurate and
				  complete. Data to be submitted may include, but shall not be limited to, the
				  following:
(1) the total number of contracts
				  issued within the reporting period and the total number of contracts in force
				  which are covered by the stop loss fund;
(2) the number of qualifying individual
				  health insurance contracts issued which do not provide coverage for
				  dependents;
(3) the number of
				  qualifying small employer health insurance contracts where the employer elects
				  not to make dependent coverage available to employees;
(4) the total number of primary insureds, the
				  total number of dependents covered, and the total number of child dependents
				  covered (a breakdown of these totals by geographic region may be
				  required);
(5) total premium earned
				  and per member per month premium earned for all contracts covered by the stop
				  loss fund for the reporting period;
(6) claims payment data, reported
				  individually for each covered member and/or for each covered member for whom
				  the health maintenance organization or participating insurer has paid claims
				  eligible for reimbursement;
(7)
				  total claims eligible for reimbursement year to date; and
(8) paid claims continuance tables containing
				  the number of claimants and the total number of claims paid by claimant dollar
				  intervals. The superintendent shall provide a written and electronic
				  spreadsheet with specific claimant dollar intervals and any partitions of paid
				  claims other than by stop loss fund.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.1 - Preamble

Current through Register Vol. 46, No. 28, July 10, 2024
(a) As enacted by
				Part SS of Chapter 54 of the Laws of 2016, Insurance Law section
				4235(n)(1) requires the
				superintendent, in consultation with the chair of the workers' compensation
				board, to determine by regulation whether family leave benefits coverage issued
				pursuant to Article 9 of the Workers' Compensation Law shall be experience
				rated or community rated. Pursuant to Insurance Law section
				4235(n)(1), if the
				determination is made to community rate such coverage, then the regulation may
				also include subjecting the family leave benefits coverage to a risk adjustment
				mechanism.
(b) As enacted by Part
				SS of Chapter 54 of the Laws of 2016, Insurance Law section
				4235(n)(1) also authorizes
				the superintendent to establish the rates for any community rated family leave
				benefits coverage and to apply commonly accepted actuarial principles to
				establish community rated family leave benefits coverage rates that are not
				excessive, inadequate or unfairly discriminatory.
(c) As enacted by Part SS of Chapter 54 of
				the Laws of 2016, Workers' Compensation Law section 209(3)(b) authorizes the
				superintendent to set the maximum employee contribution for family leave
				benefits coverage.
(d) This Part
				establishes that the family leave benefits coverage issued pursuant to Article
				9 of the Workers' Compensation Law:
(1) shall
				be community rated; and
(2) may be
				subject to the risk adjustment mechanism as set forth in this Part.
The determination that family leave benefits coverage shall
				  be community rated was made to promote a fair and efficient market for family
				  leave benefits coverage. Community rating ensures that all employees are
				  charged a rate based upon the same principles and are not subject to cost
				  variations based upon age, gender, geographic location, or any other
				  demographic factor. Community rating ensures that all employees are similarly
				  treated. The determination that family leave benefits coverage may be subject
				  to a risk adjustment mechanism was made to prevent issuers from experiencing
				  disproportionate losses due to high utilization of benefits and also to
				  eliminate any disincentives that the statewide community rate would have on the
				  issuance of policies to employers with high utilization of benefits.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.2 - Applicability

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Pursuant to
				Workers' Compensation Law section 211, a covered employer shall provide family
				leave benefits to its employees in one or more of the following ways:
(1) by insuring and keeping insured the
				payment of such benefits with an issuer; or
(2) by self-funding, in which case, a covered
				employer shall furnish satisfactory proof to the chair of the workers'
				compensation board of the employer's financial ability to pay such
				benefits.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.3 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Part:
(a) Chair shall mean the chair of the
				workers' compensation board of this State.
(b) Community rated means a rating
				methodology in which the premium for all persons covered by a policy is the
				same based on the wages of the covered person and the experience of the entire
				pool of risks covered by family leave benefits coverage in the state by all
				issuers and self-funded employers without regard to utilization or expected
				utilization of the family leave benefits or any factor that may correlate with
				such utilization including, without limitation, age, gender, health status or
				occupation.
(c) Covered employer
				means an employer subject to Article 9 of the Workers' Compensation
				Law.
(d) Earned premium means the
				premium amounts due to issuers for family leave benefits coverage provided for
				a calendar year, without regard to when the premium is actually paid or
				collected.
(e) Employee means an
				employee or other self-employed person who is eligible for family leave
				benefits in accordance with Workers' Compensation Law section 203.
(f) Family leave benefits means the coverage
				for family leave set forth in Article 9 of the Workers' Compensation
				Law.
(g) Incurred claims means all
				paid claims and unpaid claims (reported and unreported) for family leave
				benefits coverage provided for a calendar year. Incurred claims for a calendar
				year shall be calculated as: claims paid during the current calendar year plus
				current end of year unpaid claim reserves minus end of year unpaid claim
				reserves for the prior calendar year minus amounts received by the issuer
				pursuant to section 380-7.7(f) of Title 12. For purposes of this calculation,
				end of year unpaid claim reserves shall be determined in accordance with
				Insurance Law section
				1303.
(h) Issuer means:
(1) an authorized insurer writing a policy;
				and
(2) subject to 363.2(c) of this
				Part, the state insurance fund of this State.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.5 - Risk Adjustment

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Pursuant to Insurance Law section
				4235(n)(1) and (2), the
				superintendent, in consultation with the chair, has determined that the family
				leave benefits provided by issuers shall be subject to a risk adjustment
				mechanism for calendar year 2018.
(b) The superintendent, in consultation with
				the chair, may determine each year thereafter whether the family leave benefits
				coverage provided by issuers in subsequent years shall be subject to a risk
				adjustment mechanism. In making such determination, the superintendent shall
				consider whether a risk adjustment mechanism facilitates a fair and efficient
				market for family leave benefits coverage. Such determination shall be made on
				or before June 30 prior to the calendar year in which the determination is
				applicable or as soon as practicable thereafter.
(c) For each year that the superintendent
				determines that a risk adjustment mechanism is applicable, this section
				establishes the process that shall be used by the superintendent to equalize
				the per member per month claim amounts among issuers by group size in order to
				protect issuers from disproportionate adverse risks in accordance with
				Insurance Law section
				4235(n)(3).
(d) Except as determined by the
				superintendent in accordance with section 363.2(c)  of this Part, every issuer
				shall be required to participate in the family leave benefits risk adjustment
				mechanism established by this section.
(e) Self-funded employers shall not be
				subject to the risk adjustment mechanism established by this section.
(f) Administration of the risk adjustment
				mechanism. The risk adjustment mechanism established by this section shall be
				administered directly by the superintendent in consultation with the chair.
				However, the superintendent, in consultation with the chair, may employ a third
				party vendor to administer the risk adjustment mechanism.
(g) Risk adjustment equalization process.
(1) The risk adjustment mechanism established
				by this section shall utilize target loss ratios and shall equalize issuers'
				loss ratios across three separate group sizes. Group size shall be determined
				as of the date of policy issuance and, in subsequent years, as of the date of
				renewal. The three group sizes are as follows:
(i) Small Group: an employer with one to 49
				employees;
(ii) Medium Group: an
				employer with 50 to 499 employees; and
(iii) Large Group: an employer with 500 or more
				employees.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.6 - Rules relating to the content and sale of policy forms for family leave benefits coverage

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Except
				as provided in subdivision (b) of this section:
(1) every policy shall include coverage for
				both disability and family leave benefits;
(2) coverage for family leave benefits shall
				only be provided by rider to a group accident and health insurance policy
				providing disability benefits pursuant to Workers' Compensation Law Article 9;
				and
(3) coverage for family leave
				benefits shall renew or terminate as of the same renewal date or termination
				date of the policy providing disability benefits.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.7 - Maximum employee contribution

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In
				accordance with Workers' Compensation Law section 209(3)(b), the superintendent
				shall set the maximum employee contribution on or before June 1, 2017 and
				annually thereafter on or before September 1.
(b) Collection of the maximum employee
				contribution shall be done in accordance with the requirements set forth in
				Workers' Compensation Law section 209.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.8 - Data collection

Current through Register Vol. 46, No. 28, July 10, 2024
(a) In
				addition to any information requested by the superintendent or the chair
				pursuant to Workers' Compensation Law section 208(2), an issuer or self-funded
				employer shall electronically submit the following data to the superintendent,
				in a manner prescribed by the superintendent:
(1) for each employer covered under a policy
				with family leave benefits and for each self-funded employer:
(i) identification of the group number, if
				applicable;
(ii) zip code of
				employer's location;
(iii)
				employer's SIC Industry code;
(iv)
				the group size as referenced in section 363.5(g)(1);
(v) the number of employees that are male and
				the number of employees that are female;
(vi) total earned premiums received for
				family leave benefits by the issuer or the total employee contributions
				received by the self-funded employer;
(vii) total amount of benefits paid for:
(a) family care pursuant to Workers'
				Compensation Law section 201(15)(a);
(b) bonding pursuant to Workers' Compensation
				Law section 201(15)(b); and
(c) a
				qualifying exigent circumstance pursuant to Workers' Compensation Law section
				201(15)(c); and
(viii)
				whether the employer provides any additional or enhanced family leave benefits
				beyond those specified in Workers' Compensation Law section 204(2) and, if so,
				a description of the additional or enhanced benefits.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.9 - Exemptions from electronic filing and submission requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An issuer or self-funded employer
				required to make an electronic filing or a submission pursuant to this Part may
				apply to the superintendent for an exemption from the requirement that the
				filing or submission be electronic by submitting a written request to the
				superintendent for approval at least 30 days before the issuer or self-funded
				employer shall submit to the superintendent the particular filing or submission
				that is the subject of the request.
(b) The request for an exemption shall:
(1) set forth the issuer's National
				Association of Insurance Commissioners number;
(2) identify the specific filing or
				submission for which the issuer or self-funded employer is applying for the
				exemption;
(3) specify whether the
				issuer or self-funded employer is making the request for an exemption based
				upon undue hardship, impracticability, or good cause, and set forth a detailed
				explanation as to the reason that the superintendent should approve the
				request; and
(4) specify whether
				the request for an exemption extends to future filings or submissions, in
				addition to the specific filing or submission identified in paragraph (2) of
				this subdivision.