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

Universal Citation: 11 NY Comp Codes Rules and Regs ยง 363.1

Current through Register Vol. 46, No. 12, March 20, 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.

(e) This Part also sets forth:

(1) the procedures for establishing the community rate, the maximum employee contribution, and any risk adjustment mechanism; and

(2) the rules relating to the content and sale of policy forms for family leave benefits coverage.

(f) Pursuant to section 361.4 of Title 12, the requirements of this Part also apply to a self-funded employer, except that the requirement of section 363.5 of this Part shall not apply to a self-funded employer.

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