New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 363 - Unprofessional Conduct › Section 363.4 - Community Rating and Procedures for Establishing Rates

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Community Rating.
(1) Pursuant to Insurance Law section
				4235(n)(1), the
				superintendent, in consultation with the chair, has determined that family
				leave benefits coverage shall be community rated.
(2) The community rate for premiums shall be
				established by the superintendent and shall apply statewide to all
				policies.
(3) The community rate
				for premiums shall be set each year by the superintendent as a defined amount
				per week per employee. The superintendent may set the community rate for
				premiums as a defined dollar amount per employee or as a percentage of an
				employee's weekly wages. The superintendent may also utilize any one of the
				following three classification methodologies in setting the community rate for
				premiums:
(i) Classification Methodology One:
				The community rate for premiums may be set as three separate rates for
				employees earning an average weekly wage of:
(a) up to one-third of the statewide average
				weekly wage;
(b) more than
				one-third and up to two-thirds of the statewide average weekly wage;
				and
(c) more than two-thirds of the
				statewide average weekly wage.
(ii) Classification Methodology Two: The
				community rate for premiums may be set as two separate rates for employees
				earning an average weekly wage of:
(a) up to
				one-half of the statewide median weekly wage; and
(b) more than one-half of the statewide
				median weekly wage.
(iii) Classification Methodology Three: The
				community rate for premiums may be set using any other series of wage
				classifications based on an employee's weekly wages that the superintendent
				determines to reasonably differentiate employees based on their respective
				wages.
(4) In
				subparagraphs (i) or (ii) of paragraph (3) of this subdivision, the community
				rated premium or the maximum employee contribution paid by each employee shall
				be the amount that corresponds to the employee's average weekly wage.
(i) Except as provided in subparagraph (ii)
				of this paragraph, the employee's average weekly wage shall be calculated using
				the average weekly wage of the employee's previous 8 weeks of employment or
				portion thereof that the employee was in such employment with the same employer
				that is collecting the employee's contribution. Once calculated for a calendar
				year, an employee's average weekly wage shall be applicable for the remainder
				of the calendar year unless the employee's wage rate, average numbers of work
				hours per week, or salary changes, in which case, the employee's average weekly
				wage shall be recalculated on a quarterly basis on January 1, April 1, July 1,
				and October 1.
(ii) In the case of
				a self-employed person, the average weekly wage for such person shall be the
				greater of the person's self-employment income, as defined in
				26
				U.S.C. §
												1402(b), for
				the previous full calendar year divided by 52 weeks, or the statewide average
				weekly wage. If there is not 52 weeks of self-employment income for the
				previous full calendar year, then the person's average weekly wage shall be the
				greater of the sum of the person's wages for the previous calendar plus the
				person's self-employment income, as defined in
				26
				U.S.C. §
												1402(b),
				divided by 52 weeks, or the statewide average weekly wage. Once calculated for
				a calendar year, a self-employed person's average weekly wage shall be
				applicable for the remainder of the calendar year.
(5) On or before June 1, 2017, and on or
				before September 1 of each year thereafter, the superintendent shall publish
				the community rate for premiums for the policy benefit period beginning on the
				following January 1. The community rate for premiums shall also be the maximum
				employee contribution regardless of whether the family leave benefits are
				provided by an issuer or a self-funded employer.