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
Universal Citation: 11 NY Comp Codes Rules and Regs ยง 363.4
Current through Register Vol. 46, No. 39, September 25, 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.
(b) Procedures for establishing rates.
(1) In accordance with Insurance Law section
4235(n)(1), in establishing the community rate for premiums, the superintendent
shall apply commonly accepted actuarial principles to establish community rated
family leave benefits coverage rates that are not excessive, inadequate or
unfairly discriminatory.
(2) In
establishing the community rate for premiums, the superintendent may use data
collected for the previous calendar year from all issuers and self-funded
employers. In addition to any information requested by the superintendent or
the chair pursuant to Workers' Compensation Law section 208(2), issuers and
self-funded employers shall report the data as required by section
363.8 of this Part.
(c) Rate submission requirements.
(1) Every issuer shall file and maintain a
current rate manual of this State that includes the following information for a
policy providing family leave benefits:
(i)
the name of issuer and policy form number on each page;
(ii) a description of the benefits under the
policy, separately describing the benefits provided pursuant to Workers'
Compensation Law section 204(2) and any additional or enhanced benefits beyond
those specified in section 204(2);
(iii) a schedule of the premium rates for any
additional or enhanced benefits beyond those specified in Workers' Compensation
Law section 204(2); and
(iv) a
schedule of expenses as a percentage of premium, including administrative
expenses, commissions, taxes, fees and expected profit.
(2) The information required by paragraph (1)
of this subdivision shall be included in separate rate manual pages for each of
the three group sizes referenced in section
363.5(g)(1) of
this Part.
(3) The rate manual
pages for family leave benefits shall be separately maintained from the rate
manual pages for all other types of insurance including disability benefits
provided pursuant to Article 9 of the Workers' Compensation Law.
(4) The rate manual pages shall be included
as part of a rate filing submitted to the superintendent. The rate filing shall
include an actuarial memorandum that includes justification of the schedules
referenced in subparagraphs (iii) and (iv) of paragraph (1) of this
subdivision, as applicable.
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