Current through Register Vol. 46, No. 12, March 20, 2024
(a) Rules relating
to an association group written pursuant to subparagraphs (B) and (K) of
paragraph (1) of subsection (c) of section
4235 of the Insurance Law having its own
community rate.
(1) At the insurer's option,
the community rate may be based upon the collective experience of only one
association group so long as the following requirements are met:
(i) the group policy issued to the
association group must have been validly issued pursuant to section
4235(c)(1)(B) or (K) of
the Insurance Law;
(ii) the
association group policy must cover at least 10,000 persons, including spouses
and dependents, in New York State;
(iii) the association group must include
members from diverse and unrelated industries or occupations; provided,
however, that this subparagraph shall not apply to any association group
insuring 20,000 or more persons, including spouses and dependents, in New York
State, which was established prior to December 31, 1991; and
(iv) the policy issued to the association
group with its own community rate is also offered on an open enrollment basis
to any other association or small group.
(2) Once an association group has been
community-rated on the basis of its collective experience, an insurer shall not
permit it to become community-rated on the basis of a broader community-rated
pool if the claims experience of the association group community-rated on its
own collective experience is worse than the claims experience of the broader
community pool. This requirement applies to replacement insurers as well as the
insurer which initially community-rated the association group. Actual claims
experience from the previous calendar year of the association group and the
broader community pool will be compared for purposes of this
provision.
(b) Rules
relating to insurers enrolling individuals and small groups through association
groups.
(1) For the purposes of this Part,
insurers may issue small group health insurance policies in New York State only
to or through groups specifically recognized as groups under subparagraphs (B),
(D), (H), (K), (L) and (M) of paragraph (1) of subsection (c) of section
4235 of the Insurance Law. Where there is
no statutory authority recognizing the group, insurers should issue individual
health insurance policies in New York State.
(2) Insurers shall not issue policies with
their own community rate to professional or occupational associations because
they fail to meet the requirements of subparagraph (a)(1)(iii) of this section.
Insurers may, however, issue policies to eligible group members of professional
or occupational associations so long as any group (not just professional or
occupational) can obtain the policy and the policy is community-rated based
upon the experience of the entire pool of risks covered by that policy without
regard to age, sex, health status or occupation.
(3) Insurers may not refuse to accept any
individual or small group on the basis that coverage through an association
group is available as an alternative to the individual or small
group.
(4) An insurer may not limit
its participation in the small group market to policies issued to association
groups. If an insurer issues policies to association groups such an insurer
must also offer such policies on an open enrollment basis to any small group
applying for such coverage.
(5) An
insurer may limit its participation in the small group market to policies
issued to or through groups other than association groups.
(c) Rules preventing insurers from using
underwriting or benefiting from information obtained from other sources
including an association.
(1) Insurers may
not use underwriting information obtained from any source to underwrite the
issuance of health insurance to association groups and persons seeking health
insurance through association groups if the information to be used in
underwriting would be prohibited if obtained directly by the insurer in an
underwriting review, application process or similar procedure.
(2) An insurer shall refuse to issue a policy
to or through any association group if the association group or anyone acting
on its behalf has performed underwriting reviews of those seeking health
insurance through the association group. Underwriting reviews by the
association group or anyone acting on its behalf means any method of screening
persons seeking health insurance from the association group whether the
screening technique is direct or indirect.
(3) Underwriting information, underwriting
review, underwriting, screening and words of similar import shall include but
not be limited to prohibited practices such as lists of excluded industries,
occupations or professions, use of medical or laboratory tests, medical
examinations, attending physician statements, questionnaires or any
investigations or reviews regarding health status or health history or any type
of different membership or status in an association group due to health
problems, disabilities, age, sex or occupation.
(d) Community-rating and open enrollment of
group members residing in New York State who are covered under group policies
delivered to a group trust outside of New York State.
(1) Group hospital and/or medical coverage,
including Medicare supplemental insurance, obtained through an out-of-state
trust covering a group of 50 or fewer employees or participating persons who
are residents of New York State must be community-rated and open enrolled in
New York State. These requirements apply to all out-of-state trusts whether or
not the certificates of coverage under such trusts are deemed to be delivered
in New York State under section
3201 of the Insurance Law. The insurer
using an out-of-state trust mechanism which covers residents of New York State
as stated in the foregoing paragraph may not have its own community rate and
the coverage of the New York State residents must be written on a policy
available to other New York State groups of 50 or fewer employees or
participating persons and must be offered at the community rate for that
policy.
(2) If the requirements of
open enrollment and community rating cannot be met because the policy form
offered through the out-of-state trust is not available to other New York State
groups of 50 or fewer employees or participating persons then such out-of-state
trust coverage may not cover New York State residents because of the inability
of the insurer to comply with the open enrollment and community rating
requirements.
(e)
Community rates based on the size of the association groups.
(1) A policy issued to an association group
covering at least one participating group member with 50 or fewer employees or
members exclusive of spouses and dependents requires the insurer to charge the
same community rate to all association members.
(2) An insurer may issue an experience rated
policy to an association group so long as all member employers or member groups
covered by that policy exceed 50 persons exclusive of spouses and dependents. A
second separate community-rated policy may be issued by an insurer to the same
association group covering all those member employers or member groups with 50
or fewer persons exclusive of spouses and dependents.
(f) Rules relating to the imposition of
pre-existing condition limitations in association group cases.
(1) An insurer issuing a policy to an
association which is subject to the provisions of sections
3231 and
4317 of the Insurance Law must also comply
with the provisions of sections
3232 and
4318 of the Insurance Law.