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 360.11 - Community rates applicable to commercial insurers, article 43 corporations, and HMOs

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Pooling of
				experience of different community-rated policies will be required where the
				superintendent determines that the policy form provides substantially similar
				benefits as another community-rated policy offered by the insurer in that
				market (individual or small group). Policies issued during different time
				periods under different forms may be determined to provide substantially
				similar benefits. Insurers should not develop separate community rates without
				substantial benefit variations. Benefit variations which shall not generally be
				considered substantial shall include, but not be limited to, variations in
				deductibles, coinsurance amounts, the number of days or visits covered or the
				adding or deleting of benefits which do not substantially affect premiums for
				the policy.
(b) The experience pool
				consisting of claims costs, marketing costs and administrative costs maintained
				for developing community rates for individuals may be separate from the
				experience pool maintained for developing community rates for groups. Insurers
				which currently utilize one experience pool for developing community rates for
				both individuals and groups are encouraged, but not required, to continue that
				practice. Insurers which currently utilize one experience pool for developing
				community rates for both small groups subject to chapter 501 and large groups
				not subject to chapter 501 are encouraged, but not required, to continue that
				practice.
(c) Rate tiers for family
				units (
e.g.,
different community rates for individuals,
				two-person families and larger families) are permitted. However, the rate
				differences must be based upon the cost differences for the different family
				units and the rate tiers must be uniformly applied. Different rate tiers may
				apply to individuals than apply to small groups.
(d) The geographic rating areas filed as of
				July 17, 1992 may be retained or altered if, as part of the review and approval
				process, the superintendent determines that:
(1) Each regional component is geographically
				distinct and separate from every other regional component.
(2) The community rate for each geographic
				region must be based on the different costs and availability of providing
				health services in the respective regions.
(3) A rate is not established for a region
				smaller than a single county.
(4) A
				proposed region does not appear to contain configurations designed to avoid, or
				segregate into a separate region, particular areas within a county. All changes
				to rating areas are subject to prior approval even after October 1, 1994 when a
				commercial insurer utilizes the alternative rate filing procedure described in
				section 3231 (e)(2)  of the Insurance Law.