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§4305
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§4305 . Group contracts.
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§4305(a)
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(a) A corporation subject to the provisions of this article may issue a group contract, provided the group of persons thereby covered conforms to the requirements of subsections §4235(c) and §4235(d) or of subparagraph §4237(a)(3)(C) of this chapter, and provided such contract and the individual certificates issued to members of the group shall comply in substance with this article. A corporation subject to the provisions of this article shall issue to the group contractholder, for delivery to each member of the insured group, a copy of the contract, or a certificate which can be in the form of a booklet setting forth in summary form a statement of the essential features of the insurance coverage. A group contract issued pursuant to (this §) shall be subject to subsections §4235(k) and §4235(l) of this chapter.
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§4305(b)
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(b) Any such contract which provides for the adjustment of the rate of premium based upon the experience thereunder shall specify the duration of the period of insurance thereunder; such period shall not exceed 3 years, provided, however, that such contract may provide that, in the absence of 1 month's prior written notice by either party to the other, it shall be automatically renewed at the termination of any period thereunder for a succeeding period of not less than 1 nor more than 3 years' duration. In any case where such contract is for a period of more than 1 year, an appropriate additional rate of premium shall be charged therefor. Any such contract may provide for the adjustment of the rate of premium based upon the experience thereunder at the end of the 1st period of insurance thereunder or at the end of any subsequent period of insurance thereunder and any such adjustment may be made retroactive only for the period of insurance immediately preceding such adjustment.
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§4305(c)
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(c)
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§4305(c)(1)
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(1) Any such contract may provide that benefits will be furnished to a member of a covered group, for himself, his spouse, his child or children, or other persons chiefly dependent upon him for support and maintenance; provided that a contract under which coverage of a dependent of a member terminates at a specified age shall, with respect to an unmarried child who is incapable of self-sustaining employment by reason of mental illness, developmental disability, mental retardation, as defined in the mental hygiene law, or physical handicap and who became so incapable prior to attainment of the age at which dependent coverage would otherwise terminate and who is chiefly dependent upon such member for support and maintenance, not so terminate while the contract remains in force and the dependent remains in such condition, if the member has within 31 days of such dependent's attainment of the termination age submitted proof of such dependent's incapacity as described herein. Notwithstanding any rule, regulation or law to the contrary, any contract under which a member elects coverage for himself, his spouse, his children or other persons chiefly dependent upon him for support and maintenance shall provide that coverage of newborn infants, including newly born infants adopted by the insured or subscriber if such insured or subscriber takes physical custody of the infant upon such infant's release from the hospital and files a petition pursuant to §100 c the domestic relations law within 30 days of birth; and provided further that no notice of revocation to the adoption has been filed pursuant to §100 b the domestic relations law consent to the adoption has not been revoked, shall be effective from the moment birth for injury or sickness including the necessary care treatment medically diagnosed congenital defects birth abnormalities including premature birth, except that in cases adoption, coverage the initial hospital stay shall not be required where a birth parent has insurance coverage available for the infant's care. This provision regarding coverage newborn infants shall not apply to 2 person coverage. In the case of individual or 2 person coverages the corporation must also permit the person to whom the certificate is issued to elect such coverage of newborn infants from the moment of birth. If notification and/or payment of an additional premium or contribution is required to make coverage effective for a newborn infant, the coverage may provide that such notice and/or payment be made within no less than 30 days of the day of birth to make coverage effective from the moment of birth. This election shall not be required in the case of student insurance or where the group's plan does not provide coverage for dependent children.
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§4305(c)(2)
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(2) Any such contract under which coverage of a dependent spouse or group member would terminate upon such spouse or group member attaining the age prescribed in subchapter XVIII of the Social Security Act, 42 U. S. C. §1395 et seq. ("Medicare"), as the age of 1st eligibility for the benefits provided by such law shall not so terminate, if such dependent spouse is not then eligible for all of such benefits, for as long as the contract remains in force and such dependent spouse remains ineligible to receive any of such "Medicare" benefits, provided proof of such ineligibility is submitted to the corporation within 31 days of the date notice of termination of coverage is sent by 1st class mail by the corporation to the last known address of the policyholder.
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§4305(d)
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(d)
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§4305(d)(1)
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(1) A group contract issued pursuant to (this §) shall contain a provision to the effect that in case of a termination of coverage under such contract of any member of the group because of (I) termination for any reason whatsoever of his employment or membership, if he has been covered under the group contract for at least 3 months, or (II) termination for any reason whatsoever of the group contract itself unless the group contract holder has replaced the group contract with similar and continuous coverage for the same group whether insured or self-insured, he shall be entitled to have issued to him by the corporation, without evidence of insurability, upon application therefor and payment of the 1st premium made to the corporation within 45 days after termination of the coverage, an individual direct payment contract, covering such member and his eligible dependents who were covered by the group contract, which provides coverage most nearly comparable to the type of coverage under the group contract, which coverage shall be no less than the minimum standards for basic hospital, basic medical, or major medical as provided for in insurance department regulation; provided, however, that if the corporation does not issue such a major medical contract, then to a comprehensive or comparable type of coverage which is most commonly being sold to group remitting agents. Notwithstanding the previous sentence, a corporation may elect to issue a standardized individual enrollee contract pursuant to §4320 §2 of this article in lieu of a major medical contract, comprehensive or comparable type of coverage required to be offered upon conversion from an indemnity contract. The conversion privilege afforded herein shall also be available: (A) upon the divorce or annulment of the marriage of a member, to the divorced spouse or former spouse of such member, (B) upon the death of the member, to the surviving spouse and other dependents covered under the contract, and (C) to a dependent if no longer within the definition in the contract.
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§4305(d)(2)
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(2) The effective date of the coverage provided by the individual direct payment contract shall be the date of the termination of the individual's coverage under the group contract. The individual direct payment converted contract may exclude any condition excluded by the group contract. The individual direct payment contract shall not exclude any other pre-existing conditions but the benefits provided under the individual direct payment converted contract may be reduced by the amount of any such benefits provided under the group contract after the termination of the individual's coverage thereunder and during the 1st contract year of such individual direct payment converted contract the benefits provided under the contract may be reduced so that they are not in excess of those that would have been provided had the individual's contract under the group contract remained in force and effect. The corporation shall not be required to issue such individual direct payment converted contract covering any person if it appears that such person shall then be covered by another individual contract providing similar coverage or if it shall appear that such person is covered by or eligible to be covered by a group contract or policy providing similar benefits or is provided with similar benefits required by any statute or provided by any welfare plan or program, which together with the individual direct payment converted contract would result in over-insurance or duplication of benefits according to standards on file with the superintendent of insurance relating to individual contracts. The individual direct payment converted contract may include a provision whereby the corporation may request information when any payment is due under the contract of any person covered thereunder as to whether he is then covered by another contract or by a policy providing similar benefits or is then covered by a group contract or policy providing similar benefits or is then provided with similar benefits required by any statute or provided by any welfare plan or program. If any such person is so covered or so provided and fails to furnish the details of such coverage when requested, the benefits payable under the individual direct payment converted contract may be based on the hospital, surgical or medical expenses actually incurred after excluding expenses to the extent they are payable under such other coverage or provided under such statute, plan or program. In the event the benefits provided or payable are reduced in accordance with the provisions of (this sub§) the corporation shall return such portion of the premium paid as shall exceed the pro rata portion of the benefits thus determined.
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§4305(d)(3)
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(3)
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§4305(d)(3)(A)
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(A) Each member in the insured group, but not his dependents, shall be given written notice of such conversion privilege provided in (¶ (1)) hereof and its duration within 15 days after the date of termination of coverage under the group contract, provided that if such notice be given more than 15 days but less than 90 days after the date of termination of coverage under the group contract the time allowed for the exercise of such conversion privilege shall be extended for 45 days after the giving of such notice. If such notice is not given within 90 days after the date of termination of coverage under the group contract the time allowed for the exercise of such conversion privilege shall expire at the end of such 90 days.
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§4305(d)(3)(B)
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(B) Written notice by the contract holder given to the member or sent by 1st class mail to the member at his last known address, or written notice by the corporation which issued the group contract sent by 1st class mail to the member at the last address furnished to the corporation by the contract holder, shall be deemed full compliance with the provisions of (this ¶) for the giving of notice.
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§4305(d)(3)(C)
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(C) A group contract issued pursuant to (this §) may contain a provision to the effect that notice of such conversion privilege and its duration shall be given by the contract holder to each certificate holder upon termination of his group coverage.
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§4305(d)(4)
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(4) A group contract to be issued to a social services district pursuant to §365 of the social services law by a corporation subject to the provisions of this article need not, subject to the approval of the superintendent, provide for the issuance of individual certificates and may omit or modify any of the other provisions required to be contained in such contract, provided that the superintendent deems such omission or modification suitable for the character of the coverage provided.
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§4305(e)
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(e) In addition to the conversion privilege afforded by subsection (this §)(d) ,a group contract issued by a hospital service, health service or medical expense indemnity corporation shall provide that if all or any portion of the insurance on an employee or member insured under the policy ceases because of termination of employment or membership in the class or classes eligible for coverage under the policy, such employee or member shall be entitled without evidence of insurability upon application to continue his insurance for himself or herself and his or her eligible dependents, subject to all of the group contract's terms and conditions applicable to those forms of benefits and to the following conditions:
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§4305(e)(1)
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(1) Continuation shall cease on the date which the employee, member or dependant 1st becomes, after the date of election: (A) entitled to coverage under title XVIII of the United States Social Security Act (Medicare) as amended or superseded; or (B) covered as an employee, member or dependent by any other insured or uninsured arrangement which provides hospital, surgical or medical coverage for individuals in a group which does not contain any exclusion or limitation with respect to any pre-existing condition of such employee, member or dependent.
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§4305(e)(2)
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(2)
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§4305(e)(2)(A)
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(A) An employee or member who wishes continuation of coverage must request such continuation in writing within the 60 day period following the later of: (i) the date of such termination; or (ii) the date the employee is sent notice by 1st class mail of the right of continuation by the group policyholder.
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§4305(e)(2)(B)
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(B) An employee or member who wishes continuation of coverage under subparagraph (this sub§)(4)(D) must give notice to the employer or group policyholder within 60 days of the determination under title II or title XVI of the United States Social Security Act that such employee or member was disabled at the time of termination of employment or membership or at any time during the 1st 60 days of continuation of coverage.
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§4305(e)(3)
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(3) An employee or member electing continuation must pay to the group policyholder or his employer, but not more frequently than on a monthly basis in advance, the amount of the required premium payment, but not more than 102% of the group rate for the benefits being continued under the group contract on the due date of each payment. The employee's or member's written election of continuation, together with the 1st premium payment required to establish premium payment on a monthly basis in advance, must be given to the policyholder or employer within 60 days of the date the employee's or member's benefits would otherwise terminate.
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§4305(e)(4)
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(4) Subject to paragraph (this sub§)(1) ,continuation of benefits under the group contract for any person shall terminate at the 1st to occur of the following:
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§4305(e)(4)(A)
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(A) The date 18 months after the date the employee's or member's benefits under the contract would otherwise have terminated because of termination of employment or membership; or
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§4305(e)(4)(B)
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(B) The end of the period for which premium payments were made, if the employee or member fails to make timely payment of a required premium payment; or
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§4305(e)(4)(C)
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(C) In the case of an eligible dependent of an employee or member, the date 36 months after the date such person's benefits under the contract would otherwise have terminated by reason of:
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§4305(e)(4)(C)(i)
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(i) the death of the employee or member;
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§4305(e)(4)(C)(ii)
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(ii) the divorce or legal separation of the employee or member from his or her spouse;
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§4305(e)(4)(C)(iii)
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(iii) the employee or member becoming entitled to benefits under title XVIII of the United States Social Security Act (Medicare); or
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§4305(e)(4)(C)(iv)
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(iv) a dependent child ceasing to be a dependent child under the generally applicable requirements of the contract; or
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§4305(e)(4)(D)
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(D) In the case of an employee or member who is determined, under title II or title XVI of the Social Security Act, to have been disabled at the time of termination of employment or membership or at any time during the 1st 60 days of continuation of coverage, the date 29 months after the date the employee's or member's benefits under the contract would otherwise have terminated because of termination of employment or membership; provided, however, that if such employee or member is no longer disabled, the benefits provided in (this sub¶) shall terminate the later of (i) the date provided by subparagraph this paragraph, or iiA the month that begins more than 31 days after the date of the final determination under title II or title XVI of the United States Social Security Act that the employee or member is no longer disabled; or
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§4305(e)(4)(E)
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(E) The date on which the group contract is terminated or, in the case of an employee, the date his employer terminated participation under the group contract. However, if (this clause) applies and the coverage ceasing by reason of such termination is replaced by similar coverage under another group contract, the following shall apply:
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§4305(e)(4)(E)(i)
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(i) The employee or member shall have the right to become covered under that other group contract, for the balance of the period that he would have remained covered under the prior group contract in accordance with (this sub¶) had a termination described in (this sub¶) not occurred, and
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§4305(e)(4)(E)(ii)
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(ii) The minimum level of benefits to be provided by the other group contract shall be the applicable level of benefits of the prior group contract reduced by any benefits payable under the prior group contract, and
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§4305(e)(4)(E)(iii)
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(iii) The prior group contract shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred.
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§4305(e)(5)
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(5) A notification of the continuation privilege and the time period in which to request continuation shall be included in each certificate of coverage.
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§4305(e)(6)
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(6) The conversion privilege afforded by subsection (this §)(d) shall be available upon termination of the continuation of benefits described herein.
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§4305(e)(7)
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(7) (this sub§) shall not be applicable where a continuation benefit is available to the employee or member pursuant to Chapter 18 of the Employee Retirement Income Security Act, 29 U. S. C. §1161 et seq or Chapter 6A of the Public Health Service Act, 42 U. S. C. §300 bb-1 et seq.
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§4305(e)(8)
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(8)
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§4305(e)(8)(A)
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(A) Special enrollment period. An individual who does not have an election of continuation coverage as described in (this sub§) in effect on the effective date of the American Recovery and Reinvestment act of 2009, but who would be an assistance eligible individual under Title III of such act if such election were in effect, may elect continuation coverage pursuant to (this sub§) . Such election must be made no later than 60 days after the date the administrator of the group health plan (or other entity involved) provides the notice required by section 3001(a)
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§4305(e)(7)
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(7) of the American Recovery and Reinvestment act of 2009. The administrator of the group health plan (or other entity involved) shall provide such individuals with additional notice of the right to elect coverage pursuant to (this ¶) within 60 days of the date of enactment of the American Recovery and Reinvestment act of 2009.
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§4305(e)(7)(B)
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(B) Continuation coverage elected pursuant to subparagraph (this ¶)(A) shall commence with the 1st period of coverage beginning on or after the date of the enactment of the American Recovery and Reinvestment act of 2009 and shall not extend beyond the period of continuation coverage that would have been required if the coverage had instead been elected pursuant to paragraph (this sub§)(2) .
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§4305(e)(7)(C)
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(C) With respect to an individual who elects continuation coverage pursuant to subparagraph (this ¶)(A) ,the period beginning on the date of the qualifying event and ending on the date of the 1st period of coverage on or after the enactment of the American Recovery and Reinvestment act of 2009 shall be disregarded for purposes of determining the 63 day period referred to in §4318 of this article.
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§4305(f)
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(f) Any contract and certificate, other than 1 issued in fulfillment of the continuing care responsibilities of an operator of a continuing care retirement community in accordance with article 46 of the public health law, made available because of residence in a particular facility, housing development, or community shall contain the following notice in 12 point type in bold face on the 1st page: "NOTICE-THIS CONTRACT (CERTIFICATE) DOES NOT MEET THE REQUIREMENTS of A CONTINUING CARE RETIREMENT CONTRACT. AVAILABILITY of THIS COVERAGE WILL NOT QUALIFY A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY. "
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§4305(g)
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(g) In addition to all the rights of conversion and continuation otherwise provided for herein, employees or members insured under the contract who are also members of a reserve component of the armed forces of the United States, including the National Guard, shall be entitled to have supplementary conversion and continuation rights in certain circumstances as follows:
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§4305(g)(1)
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(1) if the employee or member insured enters upon active duty as defined in subsection (this §),(h) and the employer or group contract holder does not voluntarily maintain coverage for such employee or member insured, the employee or member insured shall be entitled to have his or her coverage continued under the group contract in accordance with the conditions and limitations contained in paragraph (this sub§)(7) and have issued at the end of the period of continuation an individual conversion policy subject to the terms of (this sub§) . The effective date for the conversion policy shall be the day following the termination of insurance under the group policy, or if there is a continuation of coverage, on the day following the end of the period of continuation.
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§4305(g)(2)
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(2) if the employer or group contract holder does not voluntarily maintain coverage for the employee or member insured during the period of active duty, and such employee or member insured does not elect the supplementary conversion and continuation rights provided for herein, coverage for such employee or member insured shall be suspended during the period of active duty.
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§4305(g)(3)
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(3) if the employee or member insured elects the supplementary continuation right provided for herein or coverage under the group plan is suspended, and such employee or member insured dies during the period of active duty, the conversion right provided by (this §) shall be available to the surviving spouse and children, and shall be available to a child solely with respect to himself or herself upon his or her attaining the limiting age of coverage under the group contract while covered as a dependent thereunder. It shall also be available upon the divorce or annulment of the marriage of the employee or member insured, to the former spouse of such employee or member insured, if such divorce or annulment occurs during the period of active duty.
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§4305(g)(4)
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(4) if the employee or member insured elects the supplementary conversion and continuation right provided for herein or coverage under the group plan is suspended, and such employee or member insured is either reemployed or restored to participation in the group upon return to civilian status, he or she shall be entitled to resume participation in insurance offered by the group pursuant to (this §) ,with no limitations or conditions imposed as a result of such period of active duty except as set forth in (sub¶ (A)) and (sub¶ (B)) herein. The right of resumption provided for herein shall extend to coverage for the spouse and dependents of the employee or member insured and shall be in addition to other existing rights granted pursuant to state and federal laws and regulations and shall not be deemed to qualify or limit such rights in any way. No exclusion or waiting period may be imposed in connection with coverage of a health or physical condition of a person entitled to such right of resumption, or a health or physical condition of any other person who is covered by the policy unless:
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§4305(g)(4)(A)
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(A) the condition arose during the period of active duty and the condition has been determined by the secretary of veterans affairs to be a condition incurred in the line of duty; or
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§4305(g)(4)(B)
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(B) a waiting period was imposed and had not been completed prior to the period of suspension; in no event, however, shall the sum of the waiting periods imposed prior to and subsequent to the period of suspension exceed the length of the waiting period originally imposed.
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§4305(g)(5)
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(5) if the employee or member insured elects the supplementary conversion and continuation coverage provided for herein:
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§4305(g)(5)(A)
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(A) when such employee or member insured is either reemployed or restored to participation in the group, coverage under the supplementary rights provided for herein shall terminate on the date that coverage is effective due to resumption of participation in the group.
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§4305(g)(5)(B)
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(B) when such employee or member insured is not reemployed or restored to participation in the group upon return to civilian status, he or she shall be entitled to the conversion and continuation rights provided by subsections (this §)(d) and (this §)(e) .
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§4305(g)(5)(B)(i)
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(i) To elect an individual conversion contract pursuant to subsection (this §)(d) ,the employee or member insured must apply to the insurer within 31 days of the termination of active duty or discharge from hospitalization incident to such active duty, which hospitalization continues for a period of not more than 1 year. Upon commencement of coverage under the conversion right provided pursuant to subsection (this §)(d) ,coverage under the supplementary continuation right provided for herein shall terminate.
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§4305(g)(5)(B)(ii)
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(ii) To elect continuation of coverage pursuant to subsection (this §)(e) ,the employee or member insured must request such continuation of the employer within 31 days of the termination of active duty or discharge from hospitalization incident to such active duty, which hospitalization continues for a period of not more than 1 year. Upon commencement of coverage under the continuation right provided pursuant to subsection (this §)(e) ,coverage under the supplementary continuation right provided for herein shall terminate. The employee or member insured shall be entitled to have issued at the end of the period of continuation an individual conversion contract.
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§4305(g)(6)
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(6) if coverage under the group plan is suspended during the period of active duty:
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§4305(g)(6)(A)
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(A) when the employee or member insured returns to participation in the group plan, coverage under the group plan shall be retroactive to the date of termination of the period of active duty.
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§4305(g)(6)(B)
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(B) when such employee or member insured is not reemployed or restored to participation in the group upon return to civilian status, he or she shall be entitled to the conversion and continuation rights provided by subsections (this §)(d) and (this §)(e) .
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§4305(g)(6)(B)(i)
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(i) To elect an individual conversion contract pursuant to subsection (this §)(d) ,the employee or member insured must apply to the insurer within 31 days of the termination of active duty or discharge from hospitalization incident to such active duty, which hospitalization continues for a period of not more than 1 year.
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§4305(g)(6)(B)(ii)
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(ii) To elect continuation of coverage pursuant to subsection (this §)(e) ,the employee or member insured must request such continuation of the employer within 31 days of the termination of active duty or discharge from hospitalization incident to such active duty, which hospitalization continues for a period of not more than 1 year. The employee or member insured shall be entitled to have issued at the end of the period of continuation an individual conversion contract.
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§4305(g)(7)
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(7) A group contract providing hospital, surgical or medical expense insurance for other than accident only shall provide that if all or any portion of the insurance on an employee or member insured under the contract ceases because the employee or member insured is ordered to active duty as defined in subsection (this §)(h) ,such employee or member insured shall be entitled, without evidence of insurability, upon application to continue his or her hospital, surgical or medical expense insurance for himself or herself and his or her eligible dependents, under the supplementary conversion and continuation rights provided for herein, subject to all of the group policy's terms and conditions applicable to those forms of benefits and to the following conditions:
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§4305(g)(7)(A)
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(A) continuation shall cease on the date which the employee, member or dependant 1st becomes, after the date of election: (i) entitled to coverage under title XVIII of the United States Social Security Act (Medicare) as amended or superseded or (ii) covered as an employee, member or dependent by any other insured or uninsured arrangement which provides hospital, surgical or medical coverage for individuals in a group, except that the coverage available to active duty members of the uniformed services and their family members shall not be considered a group under the terms of (this sub§) and except that the group insurance contract conversion option of (this §) shall not be considered as such an arrangement under which an employee, member or dependent could become covered.
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§4305(g)(7)(B)
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(B) an employee or member insured who wishes continuation of coverage pursuant to (this sub§) must request such continuation in writing within 60 days of being ordered to active duty.
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§4305(g)(7)(C)
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(C) an employee or member insured electing continuation pursuant to (this sub§) must pay to the group contract holder or his or her employer, but not more frequently than on a monthly basis in advance, the amount of the required premium payment, but not more than the group rate for the benefits being continued under the group contract on the due date of each payment.
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§4305(g)(8)
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(8) The supplementary conversion and continuation rights provided for herein shall apply to:
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§4305(g)(8)(A)
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(A) contracts not covered by Chapter 18 of the Employee Retirement Income Security Act, 29 U. S. C. §1161 et seq or Chapter 6A of the Public Health Service Act, 42 U. S. C. section 300bb-1 et seq;
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§4305(g)(8)(B)
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(B) contracts covered by Chapter 18 of the Employee Retirement Income Security Act, 29 U. S. C. §1161 et seq or Chapter 6A of the Public Health Service Act, 42 U. S. C. section 300bb-1 et seq, when active duty for reservists and the refusal of an employer to voluntarily maintain coverage for such period of active duty is not considered a qualifying event.
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§4305(h)
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(h) To be entitled to the right defined in subsection (this §)(g) a person must be a member of a reserve component of the armed forces of the United States, including the National Guard, who either:
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§4305(h)(1)
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(1) voluntarily or involuntarily enters upon active duty (other than for the purpose of determining his or her physical fitness and other than for training), or
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§4305(h)(2)
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(2) has his or her active duty voluntarily or involuntarily extended during a period when the president is authorized to order units of the ready reserve or members of a reserve component to active duty, provided that such additional active duty is at the request and for the convenience of the federal government, and
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§4305(h)(3)
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(3) serves no more than 4 years of active duty.
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§4305(j)
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(j)
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§4305(j)(1)
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(1) Except as provided in (this §) ,if a corporation delivers or issues for delivery in this state a group or blanket contract which provides hospital, surgical or medical expense coverage for other than accident only, the corporation must renew or continue in force such coverage at the option of the contract holder.
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§4305(j)(2)
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(2) A corporation may nonrenew or discontinue coverage under such a group or blanket contract based only on 1 or more of the following:
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§4305(j)(2)(A)
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(A) The contract holder or a participating entity has failed to pay premiums or contributions in accordance with the terms of the contract or the corporation has not received timely premium payments.
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§4305(j)(2)(B)
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(B) The contract holder or a participating entity has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the contract.
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§4305(j)(2)(C)
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(C) The contract holder has failed to comply with a material plan provision relating to employer contribution or group participation rules, as permitted under §4235 of this chapter.
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§4305(j)(2)(D)
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(D) The corporation is ceasing to offer group or blanket contracts in a market in accordance with paragraph (this sub§)(3) .
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§4305(j)(2)(E)
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(E) The contract holder ceases to meet the requirements for a group under §4235 of this chapter or a participating employer, labor union, association or other entity ceases membership or participation in the group to which the contract is issued. Coverage terminated pursuant to (this ¶) shall be done uniformly without regard to any health status-related factor relating to any covered individual.
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§4305(j)(2)(F)
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(F) In the case of a corporation that offers a group or blanket contract in a market through a network plan, there is no longer any enrollee in connection with such plan who lives, resides or works in the operating area of the corporation (or in the area for which the corporation is authorized to do business).
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§4305(j)(2)(G)
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(G) Such other reasons as are acceptable to the superintendent and authorized by the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, and any later amendments or successor provisions, or by any federal regulations or rules that implement the provisions of the Act.
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§4305(j)(3)
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(3)
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§4305(j)(3)(A)
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(A) In any case in which a corporation decides to discontinue offering a particular class of group or blanket contract of hospital, surgical or medical expense insurance offered in the small or large group market, the contract of such class may be discontinued by the corporation in accordance with this chapter in such market only if:
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§4305(j)(3)(A)(i)
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(i) the corporation provides written notice to each contract holder provided coverage of this class in such market (and to all participants and beneficiaries covered under such coverage) of such discontinuance at least 90 days prior to the date of discontinuance of such coverage;
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§4305(j)(3)(A)(ii)
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(ii) the corporation offers to each contract holder provided coverage of this class in such market, the option to purchase all (or, in the case of the large group market, any) other hospital, surgical and medical expense coverage currently being offered by the corporation to a group in such market; and
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§4305(j)(3)(A)(iii)
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(iii) in exercising the option to discontinue coverage of this class and in offering the option of coverage under item (this sub¶)(ii) ,the corporation acts uniformly without regard to the claims experience of those contract holders or any health status-related factor relating to any subscribers covered or new subscribers who may become eligible for such coverage.
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§4305(j)(3)(B)
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(B) In any case in which a corporation elects to discontinue offering all hospital, surgical and medical expense coverage in the small group market or the large group market, or both markets, in this state, health insurance coverage may be discontinued by the corporation only if:
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§4305(j)(3)(B)(i)
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(i) the corporation provides written notice to the superintendent and to each contract holder (and participants and beneficiaries covered under such coverage) of such discontinuance at least 180 days prior to the date of the discontinuance of such coverage;
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§4305(j)(3)(B)(ii)
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(ii) all hospital, surgical and medical expense coverage issued or delivered for issuance in this state in such market or markets is discontinued and coverage under such contracts in such market or markets is not renewed; and
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§4305(j)(3)(B)(iii)
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(iii) in addition to the notice to the superintendent referred to in item (this sub¶)(i) ,the corporation must provide the superintendent with a written plan to minimize potential disruption in the marketplace occasioned by its withdrawal from the market.
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§4305(j)(3)(C)
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(C) In the case of a discontinuance under subparagraph (this ¶)(B) in a market, the corporation may not provide for the issuance of any group or blanket contract of hospital, surgical or medical expense insurance in that market in this state during the 5- year period beginning on the date the discontinuance the last health insurance contract not so renewed.
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§4305(j)(4)
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(4) At the time of coverage renewal, an insurer may modify the health insurance coverage for a group or blanket contract offered to a large or small group contract holder so long as such modification is consistent with this chapter and effective on a uniform basis among all small group contract holders with that contract.
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§4305(j)(5)
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(5) For purposes of (this sub§) the term "network plan" shall mean a health insurance contract under which the financing and delivery of health care (including and services paid for as such care) are provided, in whole or in part, through a defined set of providers under contract either with the corporation or another entity that has contracted with the corporation.
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§4305(k)
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(k)
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§4305(k)(1)
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(1) No corporation delivering or issuing for delivery in this state a group or blanket contract which provides hospital, surgical or medical expense coverage shall establish rules for eligibility (including continued eligibility) of any individual or dependent of the individual to enroll under the contract based on any of the following health status-related factors:
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§4305(k)(1)(A)
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(A) Health status.
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§4305(k)(1)(B)
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(B) Medical condition (including both physical and mental illnesses).
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§4305(k)(1)(C)
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(C) Claims experience.
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§4305(k)(1)(D)
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(D) Receipt of health care.
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§4305(k)(1)(E)
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(E) Medical history.
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§4305(k)(1)(F)
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(F) Genetic information.
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§4305(k)(1)(G)
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(G) Evidence of insurability (including conditions arising out of acts of domestic violence).
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§4305(k)(1)(H)
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(H) Disability.
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§4305(k)(2)
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(2) For purposes of paragraph (this sub§)(1) ,rules for eligibility include rules defining any applicable waiting periods for such enrollment.
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§4305(k)(3)
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(3) No corporation may, on the basis of any health status-related factor in relation to the subscriber or dependent of the subscriber, require any subscriber (as a condition of enrollment or continued enrollment under the contract) to pay a premium or contribution which is greater than such premium for a similarly situated subscriber enrolled in the plan.
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§4305(k)(4)
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(4) Nothing in (this sub§) shall require a corporation to issue a group or blanket contract to a group comprised of 51 or more lives exclusive of spouses and dependents.
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§4305(k)(5)
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(5) Where an eligible subscriber or dependent of a subscriber rejects initial enrollment in a group or blanket contract that provides hospital, surgical or medical expense insurance, a corporation shall permit a subscriber or dependent of a subscriber to enroll for coverage under the terms of the contract if each of the following conditions are met:
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§4305(k)(5)(A)
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(A) The subscriber or dependent was covered under another plan or contract at the time coverage was initially offered.
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§4305(k)(5)(B)
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(B)
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§4305(k)(5)(B)(i)
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(i) Coverage was provided in accordance with continuation required by federal or state law and was exhausted; or
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§4305(k)(5)(B)(ii)
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(ii) Coverage under the other plan or contract was subsequently terminated as a result of loss of eligibility for 1 or more of the following reasons:
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§4305(k)(5)(B)(ii)(I)
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(I) termination of employment;
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§4305(k)(5)(B)(ii)(II)
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(II) termination of the other plan or contract;
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§4305(k)(5)(B)(ii)(III)
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(III) death of the spouse;
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§4305(k)(5)(B)(ii)(IV)
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(IV) legal separation, divorce or annulment;
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§4305(k)(5)(B)(ii)(V)
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(V) reduction in the number of hours of employment; or
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§4305(k)(5)(B)(iii)
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(iii) Contract holder contributions toward the payment of premium for the other plan or contract were terminated.
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§4305(k)(5)(C)
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(C) Coverage must be applied for within 30 days of termination for 1 of the reasons set forth in subparagraph (this ¶)(B) .
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§4305(k)(6)
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(6) With respect to group or blanket contracts delivered or issued for delivery in this state covering between 2 and 50 employees or members, the provisions of (this sub§) shall in no way diminish the rights of such groups pursuant to §4317 of this article. Source Data downloaded: 2009-04-09 15: 12: 49; Processed: 2009-05-08 15: 36: 09
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