New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter A - Life, Accident and Health Insurance › Part 52 - Minimum Standards For Form, Content And Sale Of Health Insurance, Including Standards Of Full And Fair Disclosure › Section 52.18 - Prohibited provisions and coverages

Current through Register Vol. 46, No. 28, July 10, 2024
(a) General rules.
(1) References to sources to determine
				  factual situations, such as employee status, membership in a collective
				  bargaining unit or a union, other benefits, salary, termination of employment
				  or membership, are not incorporations by reference within the meaning of
				  section 142(1) of the Insurance Law. Source documents or relevant excerpts
				  therefrom referred to for such data as the plan of benefits expressed in a
				  collective bargaining agreement or trust instrument shall accompany the policy
				  filing.
(2) No policy or
				  certificate shall be designated "basic" or "major medical" unless it provides
				  at least the minimum benefits in section
				  52.5,
				  52.6 or
				  52.7  of
				  this Part, respectively. Policies meeting the definition of section
				  52.8,
				  52.9 or
				  52.10 
				  of this Part shall not be designated in any manner inconsistent with the
				  applicable definition or which would encourage misrepresentation of the actual
				  coverage provided.
(3) Where a
				  policy is written that provides at least the coverages required for both basic
				  hospital insurance under section
				  52.5  of
				  this Part and basic medical insurance under section
				  52.6, the
				  allowable deductible may be applied to the combined coverage.
(4) Where a policy is written that provides
				  at least the coverages required for both basic hospital insurance under section
				  52.5  of
				  this Part and basic medical insurance under section
				  52.6, the
				  required anesthetic coverage may be provided as part of the miscellaneous
				  hospital benefit instead of a separate anesthetic benefit, provided that the
				  limit of the miscellaneous hospital benefit is sufficient to meet the combined
				  minimum requirements of both the miscellaneous hospital benefit of basic
				  hospital insurance and the anesthesia benefit of basic medical
				  insurance.
(5) Policies which
				  provide benefits as described in
				  42 U.S.C.
				  section 300 gg - 91(c), except for policies
				  defined in sections
				  52.11,
				  52.12,
				  52.13
				  and
				  52.14
				  of this Part and policies subject to the requirements of section
				  52.20 
				  of this Part, may not exclude, limit or reduce coverage for a loss due to a
				  preexisting condition for a period greater than 12 months following the
				  effective date of an insured's coverage. Where a policy providing such benefits
				  is delivered or issued for delivery to a group which includes persons aged 65
				  or older, such policy shall not contain any provision which excludes, limits or
				  reduces coverage for a loss due to a preexisting condition for those aged 65 or
				  older for a period greater than six months following the effective date of an
				  insured's coverage. For purposes of this paragraph, a preexisting condition is
				  one for which medical advice was given, treatment was recommended by or
				  received from a physician, within six months before the effective date of an
				  insured's coverage.
(6)
(i) Insurers issuing accident and health
				  certificates which provide hospital or medical coverage on an expense incurred
				  or indemnity basis to a person(s) eligible for Medicare shall provide to those
				  applicants a Guide to Health Insurance for People with Medicare in the form
				  developed jointly by the National Association of Insurance Commissioners and
				  the Health Care Financing Administration and in a type size no smaller than
				  12-point type. Delivery of the guide shall be made whether or not such
				  certificates are advertised, solicited or issued as Medicare supplement
				  insurance as defined in this regulation. Except in the case of direct response
				  insurers, delivery of the guide shall be made to the applicant at the time of
				  application and written acknowledgment of receipt of the guide shall be
				  obtained by the insurer. Direct response insurers shall deliver the guide to
				  the applicant upon request but in no event later than at the time the
				  certificate is delivered. If the guide has not been made available from the
				  Health Care Financing Administration at the time that the insurer is required
				  to deliver such guide, then the insurer shall provide the applicant with a
				  notice that the guide is presently unavailable and that it will be delivered to
				  the applicant at such time that it is available to the insurer.
(ii) For the purposes of this paragraph, form
				  means the language, format, typesize, type proportional spacing, bold
				  character, and line spacing.
(7)
(i) Any
				  accident and health insurance certificate, other than a Medicare supplement
				  certificate, a certificate issued pursuant to a contract under section 1876 of
				  the Federal Social Security Act (42 U.S.C. section
				  1395 et seq.), disability income certificate,
				  or a certificate evidencing accident and health insurance coverage under a
				  group policy issued to a group described in subparagraph (A), (B), (C) or (D)
				  of Insurance Law section
				  4235(c)(1), delivered or
				  issued for delivery in this State to persons eligible for Medicare shall notify
				  covered persons under the certificate that the certificate is not a Medicare
				  supplement plan. The notice shall either be printed on or attached to the first
				  page of the disclosure statement delivered to covered persons to comply with
				  section
				  52.54  of
				  this Part or to the first page of the certificate delivered to covered persons.
				  The notice shall be in no less than 12-point type and shall contain the
				  following language:
"THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT PLAN. If you
					 are eligible for Medicare, review the Guide to Health Insurance for People with
					 Medicare available from the company."
(ii) Where applicable, applications provided
				  to persons eligible for Medicare for the accident and health insurance
				  coverages described in subparagraph (i) of this paragraph shall disclose, using
				  the applicable statement prescribed in
				  42 U.S.C. section
				  1395 ss(d)(3)(D), the extent to which the
				  certificate duplicates Medicare. The disclosure statement shall be provided as
				  a part of, or together with, the application for the certificate.
(8)
(i) Unilateral modifications by an insurer to
				  existing accident and health coverage shall be made in accordance with
				  applicable laws upon at least 30 days' prior written notice to the
				  policyholder.
(ii) An insurer may
				  unilaterally modify the coverage for a policy of hospital, surgical or medical
				  expense insurance only at the time of coverage renewal.
(iii) Where a policyholder is contractually
				  required to provide prior written notice to terminate coverage, the notice
				  referred to in subparagraph (i) of this paragraph must be provided to such
				  policyholder no less than 14 days prior to the date by which the policyholder
				  is required to provide notice to terminate coverage.
(9) At the time of an event described in
				  42 U.S.C. section
				  1395 ss(s)(3)(B) or (F) [FN*] because of
				  which an individual loses coverage or benefits due to the termination of the
				  policy or the individual ceases enrollment under the policy, the insurer of the
				  policy from which termination or disenrollment occurs shall provide the
				  individual with written notification of his or her rights and of the
				  obligations of issuers of Medicare supplement insurance policies under Part 58
				  of this Title. If an individual loses coverage or benefits due to termination
				  of the policy, such notification must be provided contemporaneously with the
				  notification of termination. If an individual ceases enrollment under the
				  policy, such notification must be provided within 10 working days of the
				  insurer receiving notification of disenrollment.
(10) Insurers issuing policies and contracts
				  subject to the provisions of sections 3221 (k)(6) or
				  4303 (s)  of the Insurance
				  Law shall use standards and guidelines no less favorable than those established
				  and adopted by The American Society for Reproductive Medicine in relation to
				  the following:
(i) the determination of
				  infertility for the purposes of compliance with sections 3221 (k)(6)(C) and
				  4303 (s)(3)  of the
				  Insurance Law;
(ii) the
				  identification of experimental procedures and treatments not covered for the
				  diagnosis and treatment of infertility;
(iii) the identification of the required
				  training, experience and other standards for health care providers for the
				  provision of procedures and treatments for the diagnosis and treatment of
				  infertility; and
(iv) the
				  determination of appropriate medical candidates by the treating physician.
Said standards and guidelines are taken from The American
					 Society for Reproductive Medicine's Practice Committee Opinions on The
					 Definition of Experimental, The Definition of Infertility, The Guidelines for
					 the Provision of Infertility Services and The Revised Minimum Standards for
					 Invitro Fertilization, Gamete Intrafallopian Transfer and Related Procedures.
					 These Practice Committee Opinions were approved by the Practice Committee of
					 the American Society for Reproductive Medicine (formerly The American Fertility
					 Society) on March 27, 1993 and approved by the Board of Directors of the
					 American Society for Reproductive Medicine (formerly The American Fertility
					 Society) on May 17, 1993. The Practice Committee Opinions may be obtained from
					 The American Society for Reproductive Medicine formerly The American Fertility
					 Society, 1209 Montgomery Highway, Birmingham, AL 35216-2809 and are available
					 for public inspection and copying from the New York State Insurance Department
					 at either 25 Beaver Street, New York, NY 10004 or One Commerce Plaza, Albany,
					 NY 12257.
(11)
				  Repealed
(12) Repealed
(13) An insurer issuing a policy subject to
				  the provisions of Insurance Law sections
				  3217-g,
				  3221(l)(8),
				  4303(j) or
				  4306-f or Public Health Law section
				  4406-f that provides coverage for direct
				  access to s creening and referral for maternal depression performed by a
				  provider of obstetrical, gynecologic, or pediatric services of the mother's
				  choice, shall provide coverage for the screening and referral for maternal
				  depression under the mother's policy. However, if the infant is covered under a
				  different policy than the mother and the screening and referral are performed
				  by a provider of pediatric services, coverage for the screening and referral
				  shall also be provided under the policy in which the infant is
				  covered.