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§4317
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§4317 . Rating of individual and small group health insurance contracts.
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§4317(a)
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(a) No individual health insurance contract and no group health insurance contract covering between 2 and 50 employees or members of the group exclusive of spouses and dependents, including contracts for which the premiums are paid by a remitting agent for a group, hereinafter referred to as a small group, providing hospital and/or medical benefits, including Medicare supplemental insurance, shall be issued in this state unless such contract is community rated and, notwithstanding any other provisions of law, the underwriting of such contract involves no more than the imposition of a pre-existing condition limitation as permitted by this article. Any individual, and dependents of such individual, and any small group, including all employees or group members and dependents of employees or members, applying for individual or small group health insurance coverage must be accepted at all times throughout the year for any hospital and/or medical coverage, including Medicare supplemental insurance, offered by the corporation to individuals or small groups in this state. Once accepted for coverage, an individual or small group cannot be terminated by the insurer due to claims experience. Termination of coverage for individuals or small groups may be based only on 1 or more of the reasons set forth in subsection §4304(c) or subsection §4305(j) of this article. For the purposes of (this §) ,"community rated" means a rating methodology in which the premium for all persons covered by a policy or contract form is the same, based on the experience of the entire pool of risks covered by that policy or contract form without regard to age, sex, health status or occupation.
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§4317(b)
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(b) Nothing herein shall prohibit the use of premium rate structures to establish different premium rates for individuals as opposed to family units or separate community rates for individuals as opposed to small groups. If a corporation is required to issue a contract to individual proprietors pursuant to subsection (this §)(f) ,such contract shall be subject to the requirements of subsection (this §)(a) .
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§4317(c)
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(c) The superintendent shall permit the use of separate community rates for reasonable geographic regions, which may, in a given case, include a single county. The regions shall be approved by the superintendent as part of the rate filing. The superintendent shall not require the inclusion of any specific geographic regions within the proposed community rated regions selected by the corporation in its rate filing so long as the corporation's proposed regions do not contain configurations designed to avoid or segregate particular areas within a county covered by the corporation's community rates.
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§4317(d)
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(d) (this §) shall also apply to contracts issued to a group defined in subsection §4235(c) , including but not limited to an association or trust of employers, if the group includes 1 or more member employers or other member groups which have 50 or fewer employees or members exclusive of spouses and dependents.
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§4317(e)
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(e)
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§4317(e)(1)
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(1) Notwithstanding any other provision of this chapter, no insurer, subsidiary of an insurer, or controlled person of a holding company system may act as an administrator or claims paying agent, as opposed to an insurer, on behalf of small groups which, if they purchased insurance, would be subject to (this §) . No insurer, subsidiary of an insurer, or controlled person of a holding company may provide stop loss, catastrophic or reinsurance coverage to small groups which, if they purchased insurance, would be subject to (this §) .
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§4317(e)(2)
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(2) (this sub§) shall not apply to coverage insuring a plan which was in effect on or before December 31st, 1991 and was issued to a group which includes member small employers or other member small groups, including but not limited to association groups, provided that (A) acceptance of additional small member employers (or other member groups comprised of 50 or fewer employees or members, exclusive of spouses and dependents) into the group on or after June 1st, 1992 and before April 1st, 1994 does not exceed an amount equal to 10% per year of the total number of persons covered under the group as of June 1st, 1992, but nothing in (this sub¶) shall limit the addition of larger member employers; (B)
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§4317(e)(2)
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(i) after April 1st, 1994, the group thereafter accepts member small employers and member small groups without underwriting by any more than the imposition of a pre-existing condition limitation as permitted by this article and the cost for participation in the group for all persons covered shall be the same based on the experience of the entire pool of risks covered under the entire group, without regard to age, sex, health status or occupation; and (ii) once accepted for coverage, an individual or small group cannot be terminated due to claims experience; (C) the insurer has registered the names of such groups, including the total number of persons covered as of June 1st, 1992, with the superintendent, in a form prescribed by the superintendent, on or before April 1st, 1993 and shall report annually thereafter until such groups comply with the provisions of subparagraph (this ¶)(B) ; and (D) the types or categories of employers or groups eligible to join the association are not altered or expanded after June 1st, 1992.
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§4317(e)(3)
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(3) A corporation may apply to the superintendent for an extension or extensions of time beyond April 1st, 1994 in which to implement the provisions of (this sub§) as they relate to groups registered with the superintendent pursuant to subparagraph (this sub§)(2)(C) ; any such extension or extensions may not exceed 2 years in aggregate duration, and the 10% per year limitation of subparagraph (this sub§)(2)(A) shall be reduced to 5% per year during the period of any such extension or extensions. Any application for an extension shall demonstrate that a significant financial hardship to such group would result from such implementation.
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§4317(f)
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(f)
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§4317(f)(1)
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(1) If the insurer issues coverage to an association group (including chambers of commerce), as defined in subparagraph §4235(c)(1)(K) of this chapter, the insurer must issue the same coverage to individual proprietors which purchase coverage through the association group as the insurer issues to groups which purchase coverage through the association group; provided, however, that an insurer which, on the effective date of (this sub§) ,is issuing coverage to individual proprietors not connected with an association group, may continue to issue such coverage provided that the coverage is otherwise in accordance with (this sub§) and all other applicable provisions of law.
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§4317(f)(2)
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(2) For coverage purchased pursuant to (this sub§) ,individual proprietors shall be classified in their own community rating category, provided however, up to and including December 31st, 2011, the premium rate established for individual proprietors purchased pursuant to paragraph (this sub§)(1) shall not be greater than 115% of the rate established for the same coverage issued to groups.
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§4317(f)(3)
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(3) The insurer may require members of the association purchasing health insurance to verify that all employees electing health insurance are legitimate employees of the employers, as documented on New York state tax form NYS-45-ATT-MN or comparable documentation. In order to be eligible to purchase health insurance pursuant to (this sub§) and obtain the same group insurance products as are offered to groups, a sole employee of a corporation or a sole proprietor of an unincorporated business or entity must (A) work at least 20 hours per week, (B) if purchasing the coverage through an association group, be a member of the association for at least 60 days prior to the effective date of the insurance policy, and (C) present a copy of the following documentation to the insurer or health plan administrator on an annual basis:
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§4317(f)(3)
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(i) NYS tax form 45-ATT, or comparable documentation of active employee status;
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§4317(f)(3)
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(ii) for an unincorporated business, the prior year's federal income tax Schedule C for an incorporated business subject to Subchapter S with a sole employee, federal income tax Schedule E for other incorporated businesses with a sole employee, a W-2 annual wage statement, or federal tax form 1099 with federal income tax Schedule F; or
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§4317(f)(3)
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(iii) for a business in business for less than 1 year, a cancelled business check, a certificate of doing business, or appropriate tax documentation; and
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§4317(f)(3)
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(iv) such other documentation as may be reasonably required by the insurer as approved by the superintendent to verify eligibility of an individual to purchase health insurance pursuant to (this sub§) .
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§4317(f)(4)
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(4) Notwithstanding the provisions of item §4235(c)(1)(K)(i)(I) of this chapter, for purposes of (this §) ,an association group shall include chambers of commerce with less than 200 members which are 501C3 or 501C6 organizations. Source Data downloaded: 2009-04-09 15: 12: 49; Processed: 2009-05-08 15: 36: 09
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