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§4326
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§4326 . Standardized health insurance contracts for qualifying small employers and individuals.
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§4326(a)
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(a) A program is hereby established for the purpose of making standardized health insurance contracts available to qualifying small employers and qualifying individuals as defined in (this §) . Such program is designed to encourage small employers to offer health insurance coverage to their employees and to also make coverage available to uninsured employees whose employers do not provide group health insurance.
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§4326(b)
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(b) Participation in the program established by this section and section4327 of this article is limited to corporations or insurers organized or licensed under this article or article 42 of this chapter and health maintenance organizations issued a certificate of authority under article 44 of the public health law or licensed under this article. Participation by all health maintenance organizations is mandatory, provided, however, that such requirements shall not apply to a health maintenance organization exclusively serving individuals enrolled pursuant to title 11 of article 5 of the social services law, title 11- D article 5 of the social services law, title 1- A article 25 of the public health law or title 18 of the federal Social Security Act, and, further provided, that such health maintenance organization shall not discontinue a contract for an individual receiving comprehensive-type coverage in effect prior to January 1st, 2004 who is ineligible to purchase policies offered after such date pursuant to this section or section4322 of this article due to the provision of 42 U. S. C. 1395ss in effect prior to January 1st, 2004. On after January 1st, 2001, all health maintenance organizations shall offer qualifying group health insurance contracts and qualifying individual health insurance contracts as defined in (this §) . For the purposes of this section and section4327 of this article, article 43 corporations or article 42 insurers which voluntarily participate in compliance with the requirements of this program shall be eligible for reimbursement from the stop loss funds created pursuant to §4327 of this article under the same terms and conditions as health maintenance organizations.
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§4326(c)
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(c) The following definitions shall be applicable to the insurance contracts offered under the program established by (this §) :
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§4326(c)(1)
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(1) A qualifying small employer is an employer that is either:
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§4326(c)(1)(A)
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(A) An individual proprietor who is the only employee of the business:
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§4326(c)(1)(A)(i)
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(i) without health insurance which provides benefits on an expense reimbursed or prepaid basis in effect during the 12 month period prior to application for a qualifying group health insurance contract under the program established by (this §) ; and
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§4326(c)(1)(A)(ii)
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(ii) resides in a household having a net household income at or below 208% of the non-farm federal poverty level (as defined and updated by the federal department of health and human services) or the gross equivalent of such net income;
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§4326(c)(1)(A)(iii)
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(iii) except that the requirements set forth in item (this sub¶)(i) shall not be applicable where an individual proprietor had health insurance coverage during the previous 12 months and such coverage terminated due to 1 of the reasons set forth in items (this §)(c)(3)(C)(i) through (this §)(c)(3)(C)(viii) ; or
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§4326(c)(1)(B)
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(B) An employer with:
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§4326(c)(1)(B)(i)
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(i) not more than 50 eligible employees;
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§4326(c)(1)(B)(ii)
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(ii) no group health insurance which provides benefits on an expense reimbursed or prepaid basis covering employees in effect during the 12 month period prior to application for a qualifying group health insurance contract under the program established by (this §) ; and
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§4326(c)(1)(B)(iii)
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(iii) at least 30% of its eligible employees receiving annual wages from the employer at a level equal to or less than $30,000. The $30,000 figure shall be adjusted periodically pursuant to subparagraph (this ¶)(F) .
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§4326(c)(1)(C)
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(C) The requirements set forth in item (this ¶)(A)(i) and in item (this ¶)(B)(ii) shall not be applicable where an individual proprietor or employer is transferring from a health insurance contract issued pursuant to the New York state small business health insurance partnership program established by §922 of the public health law or from health care coverage issued pursuant to a regional pilot project for the uninsured established by §1118 of this chapter.
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§4326(c)(1)(D)
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(D) The 12 month period set forth in item (this ¶)(A)(i) and in item (this ¶)(B)(ii) may be adjusted by the superintendent from 12 months to 18 months if he determines that the 12 month period is insufficient to prevent inappropriate substitution of other health insurance contracts for qualifying group health insurance contracts.
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§4326(c)(1)(E)
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(E) An individual proprietor or employer shall cease to be a qualifying small employer if any health insurance which provides benefits on an expense reimbursed or prepaid basis covering the individual proprietor or an employer's employees, other than qualifying group health insurance purchased pursuant to (this §) ,is purchased or otherwise takes effect subsequent to purchase of qualifying group health insurance under the program established by (this §) .
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§4326(c)(1)(F)
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(F) The wage levels utilized in subparagraph (this ¶)(B) shall be adjusted annually, beginning in 2002. The adjustment shall take effect on July 1st of each year. For July 1st, 2002, the adjustment shall be a percentage of the annual wage figure specified in subparagraph (this ¶)(B) . For subsequent years, the adjustment shall be a percentage of the annual wage figure which took effect on July 1st of the prior year. The percentage adjustment shall be the same percentage by which the current year's non-farm federal poverty level, as defined and updated by the federal department of health and human services, for a family unit of 4 persons for the 48 contiguous states and Washington, D. C., changed from the same level established for the prior year.
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§4326(c)(2)
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(2) A qualifying group health insurance contract is a group contract purchased from a health maintenance organization, corporation or insurer by a qualifying small employer which provides the benefits set forth in subsection (this §)(d) . The contract must insure not less than 50% of the employees eligible for coverage.
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§4326(c)(3)
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(3)
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§4326(c)(3)(A)
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(A) A qualifying individual is an employed person:
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§4326(c)(3)(A)(i)
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(i) who does not have and has not had health insurance with benefits on an expense reimbursed or prepaid basis during the 12 month period prior to the individual's application for health insurance under the program established by (this §) ;
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§4326(c)(3)(A)(ii)
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(ii) whose employer does not provide group health insurance and has not provided group health insurance with benefits on an expense reimbursed or prepaid basis covering employees in effect during the 12 month period prior to the individual's application for health insurance under the program established by (this §) ;
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§4326(c)(3)(A)(iii)
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(iii) resides in a household having a net household income at or below 208% of the non-farm federal poverty level (as defined and updated by the federal department of health and human services) or the gross equivalent of such net income; and
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§4326(c)(3)(A)(iv)
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(iv) is ineligible for Medicare.
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§4326(c)(3)(B)
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(B) The requirements set forth in items (this ¶)(A)(i) and (this ¶)(A)(ii) shall not be applicable where an individual is transferring from a health insurance contract issued pursuant to the voucher insurance program established by §1121 of this chapter, a health insurance contract issued pursuant to the New York state small business health insurance partnership program established by §922 of the public health law or health care coverage issued pursuant to a regional pilot project for the uninsured established by §1118 of this chapter.
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§4326(c)(3)(C)
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(C) The requirements set forth in items (this ¶)(A)(i) and (this ¶)(A)(ii) shall not be applicable where an individual had health insurance coverage during the previous 12 months and such coverage terminated due to:
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§4326(c)(3)(C)(i)
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(i) loss of employment due to factors other than voluntary separation;
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§4326(c)(3)(C)(ii)
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(ii) death of a family member which results in termination of coverage under a health insurance contract under which the individual is covered;
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§4326(c)(3)(C)(iii)
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(iii) change to a new employer that does not provide group health insurance with benefits on an expense reimbursed or prepaid basis;
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§4326(c)(3)(C)(iv)
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(iv) change of residence so that no employer-based health insurance with benefits on an expense reimbursed or prepaid basis is available;
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§4326(c)(3)(C)(v)
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(v) discontinuation of a group health insurance contract with benefits on an expense reimbursed or prepaid basis covering the qualifying individual as an employee or dependent;
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§4326(c)(3)(C)(vi)
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(vi) expiration of the coverage periods established by the continuation provisions of the Employee Retirement Income Security Act, 29 U. S. C. §1161 et seq. and the Public Health Service Act, 42 U. S. C. section 300bb-1 et seq. established by the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended, or the continuation provisions of subsection §3221(m) , subsection §4304(k) and subsection §4305(e) of this chapter;
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§4326(c)(3)(C)(vii)
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(vii) legal separation, divorce or annulment which results in termination of coverage under a health insurance contract under which the individual is covered; or
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§4326(c)(3)(C)(viii)
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(viii) loss of eligibility under a group health plan.
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§4326(c)(3)(D)
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(D) The 12 month period set forth in items (this ¶)(A)(i) and (this ¶)(A)(ii) may be adjusted by the superintendent from 12 months to 18 months if he determines that the 12 month period is insufficient to prevent inappropriate substitution of other health insurance contracts for qualifying individual health insurance contracts.
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§4326(c)(4)
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(4) A qualifying individual health insurance contract is an individual contract issued directly to a qualifying individual and which provides the benefits set forth in subsection (this §)(d) . At the option of the qualifying individual, such contract may include coverage for dependents of the qualifying individual.
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§4326(d)
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(d) The contracts issued pursuant to (this §) by health maintenance organizations, corporations or insurers and approved by the superintendent shall only provide in-plan benefits, except for emergency care or where services are not available through a plan provider. Covered services shall include only the following:
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§4326(d)(1)
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(1) inpatient hospital services consisting of daily room and board, general nursing care, special diets and miscellaneous hospital services and supplies;
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§4326(d)(2)
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(2) outpatient hospital services consisting of diagnostic and treatment services;
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§4326(d)(3)
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(3) physician services consisting of diagnostic and treatment services, consultant and referral services, surgical services (including breast reconstruction surgery after a mastectomy), anesthesia services, 2nd surgical opinion, and a 2nd opinion for cancer treatment;
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§4326(d)(4)
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(4) outpatient surgical facility charges related to a covered surgical procedure;
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§4326(d)(5)
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(5) preadmission testing;
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§4326(d)(6)
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(6) maternity care;
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§4326(d)(7)
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(7) adult preventive health services consisting of mammography screening; cervical cytology screening; periodic physical examinations no more than once every 3 years; and adult immunizations;
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§4326(d)(8)
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(8) preventive and primary health care services for dependent children including routine well-child visits and necessary immunizations;
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§4326(d)(9)
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(9) equipment, supplies and self-management education for the treatment of diabetes;
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§4326(d)(10)
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(10) diagnostic x-ray and laboratory services;
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§4326(d)(11)
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(11) emergency services;
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§4326(d)(12)
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(12) therapeutic services consisting of radiologic services, chemotherapy and hemodialysis;
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§4326(d)(13)
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(13) blood and blood products furnished in connection with surgery or inpatient hospital services; and
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§4326(d)(14)
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(14) prescription drugs obtained at a participating pharmacy. In addition to providing coverage at a participating pharmacy, health maintenance organizations may utilize a mail order prescription drug program. Health maintenance organizations may provide prescription drugs pursuant to a drug formulary; however, health maintenance organizations must implement an appeals process so that the use of non-formulary prescription drugs may be requested by a physician.
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§4326(d-1)
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(d-1) Covered services shall not include drugs, procedures and supplies for the treatment of erectile dysfunction when provided to, or prescribed for use by, a person who is required to register as a sex offender pursuant to article 6- C the correction law, provided that: (1) any denial coverage pursuant to (this sub§) shall provide the enrollee with the means obtaining additional information concerning both the denial the means challenging such denial; (2) all drugs, procedures supplies for the treatment erectile dysfunction may be subject to prior authorization by corporations, insurers or health main10ance organizations for the purposes implementing (this sub§) ; (3) the superin10dent shall promulgate regulations to implement the denial coverage pursuant to (this sub§) giving health main10ance organizations, corporations insurers at least 60 days following promulgation of the regulations to implement their denial procedures pursuant to (this sub§) .
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§4326(d-2)
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(d-2) No person or entity authorized to provide coverage under (this §) shall be subject to any civil or criminal liability for damages for any decision or action pursuant to subsection (this §)(d-1) ,made in the ordinary course of business if that authorized person or entity acted reasonably and in good faith with respect to such information.
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§4326(d-3)
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(d-3) Notwithstanding any other provision of law, if the commissioner of health makes a finding pursuant to subdivision 23 of §206 of the public health law, the superintendent is authorized to remove a drug, procedure or supply from the services covered by the standardized health insurance contract established by (this §) for those persons required to register as sex offenders pursuant to article 6- C the correction law.
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§4326(e)
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(e) The benefits provided in the contracts described in subsection (this §)(d) shall be subject to the following deductibles and copayments:
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§4326(e)(1)
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(1) in-patient hospital services shall have a $500 copayment for each continuous hospital confinement;
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§4326(e)(2)
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(2) surgical services shall be subject to a copayment of the lesser of 20% of the cost of such services or $200 per occurrence;
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§4326(e)(3)
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(3) outpatient surgical facility charges shall be subject to a facility copayment charge of $75 per occurrence;
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§4326(e)(4)
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(4) emergency services shall have a $50 copayment which must be waived if hospital admission results from the emergency room visit;
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§4326(e)(5)
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(5) prescription drugs shall have a $100 calendar year deductible per individual. After the deductible is satisfied, each 34 day supply of a prescription drug will be subject to a copayment. The copayment will be $10 if the drug is generic. The copayment for a brand name drug will be $20 plus the difference in cost between the brand name drug and the equivalent generic drug. If a mail order drug program is utilized, a $20 copayment shall be imposed on a 90 day supply of generic prescription drugs. A $40 copayment plus the difference in cost between the brand name drug and the equivalent generic drug shall be imposed on a 90 day supply of brand name prescription drugs. In no event shall the copayment exceed the cost of the prescribed drug;
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§4326(e)(6)
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(6) the maximum coverage for prescription drugs shall be $3,000 per individual in a calendar year; and
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§4326(e)(7)
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(7) all other services shall have a $20 copayment with the exception of prenatal care which shall have a $10 copayment.
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§4326(f)
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(f) Except as included in the list of covered services in subsection (this §)(d) ,the mandated and make-available benefits set forth in §3216 , §3221 of this chapter and 4303 of this article shall not be applicable to the contracts issued pursuant to (this §) . Mandated benefits included in such contracts shall be subject to the deductibles and copayments set forth in subsection (this §)(e) .
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§4326(g)
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(g) The superintendent shall be authorized to modify, by regulation, the copayment and deductible amounts described in (this §) if the superintendent determines such amendments are necessary to facilitate implementation of (this §) . On or after January 1st, 2002, the superintendent shall be authorized to establish, by regulation, 1 or more additional standardized health insurance benefit packages if the superintendent determines additional benefit packages with different levels of benefits are necessary to meet the needs of the public.
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§4326(h)
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(h) A health maintenance organization, corporation or insurer must offer the benefit package without change or additional benefits. Qualifying small employers shall be issued the benefit package in a qualifying group health insurance contract. Qualifying individuals shall be issued the benefit package in a qualifying individual health insurance contract.
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§4326(i)
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(i) A health maintenance organization, corporation or insurer shall obtain from the employer or individual written certification at the time of initial application and annually thereafter 90 days prior to the contract renewal date that such employer or individual meets the requirements of a qualifying small employer or a qualifying individual pursuant to (this §) . A health maintenance organization, corporation or insurer may require the submission of appropriate documentation in support of the certification.
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§4326(j)
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(j) Applications for qualifying group health insurance contracts and qualifying individual health insurance contracts must be accepted from any qualifying individual and any qualifying small employer at all times throughout the year. The superintendent, by regulation, may require health maintenance organizations, corporations or insurers to give preference to qualifying small employers whose eligible employees have the lowest average salaries.
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§4326(k)
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(k) All coverage under a qualifying group health insurance contract or a qualifying individual health insurance contract must be subject to a pre-existing condition limitation provision as set forth in §3232 of this chapter and 4318 of this article, including the crediting requirements thereunder. The underwriting of such contracts may not involve more than the imposition of a pre-existing condition limitation.
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§4326(l)
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(l) A qualifying small employer shall elect whether to make coverage under the qualifying group health insurance contract available to dependents of employees. Any employee or dependent who is enrolled in Medicare is ineligible for coverage, unless required by federal law. Dependents of an employee who is enrolled in Medicare will be eligible for dependent coverage provided the dependent is not also enrolled in Medicare.
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§4326(m)
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(m) A qualifying small employer must pay at least 50% of the premium for employees covered under a qualifying group health insurance contract and must offer coverage to all employees receiving annual wages at a level of $30,000 or less, and at least 1 such employee shall accept such coverage. The $30,000 wage level shall be adjusted periodically in accordance with subparagraph (this §)(c)(1)(F) . The employer premium contribution must be the same percentage for all covered employees.
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§4326(n)
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(n) Premium rate calculations for qualifying group health insurance contracts and qualifying individual health insurance contracts shall be subject to the following:
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§4326(n)(1)
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(1) coverage must be community rated and include rate tiers for individuals, 2 adult families and at least 1 other family tier. The rate differences must be based upon the cost differences for the different family units and the rate tiers must be uniformly applied. The rate tier structure used by a health maintenance organization, corporation or insurer for the contracts issued to qualifying small employers and to qualifying individuals must be the same;
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§4326(n)(2)
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(2) if geographic rating areas are utilized, such geographic areas must be reasonable and in a given case may include a single county. The geographic areas utilized must be the same for the contracts issued to qualifying small employers and to qualifying individuals. The superintendent shall not require the inclusion of any specific geographic region within the proposed community rated region selected by the health maintenance organization, corporation or insurer so long as the health maintenance organization, corporation or insurer's proposed regions do not contain configurations designed to avoid or segregate particular areas within a county covered by the health maintenance organization, corporation or insurer's community rates.
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§4326(n)(3)
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(3) claims experience under contracts issued to qualifying small employers and to qualifying individuals must be pooled for rate setting purposes. The premium rates for qualifying group health insurance contracts and qualifying individual health insurance contracts must be the same.
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§4326(o)
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(o) A health maintenance organization, corporation or insurer shall submit reports to the superintendent in such form and at times as may be reasonably required in order to evaluate the operations and results of the standardized health insurance program established by (this §) .
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§4326(p)
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(p) Notwithstanding any other provision of law, all individuals and small businesses that are participating in or covered by insurance contracts or policies issued pursuant to the New York state small business health insurance partnership program established by §922 of the public health law, the voucher insurance program established by §1121 of this chapter, or uninsured pilot programs established pursuant to chapter 703 of the laws of 1988 shall be eligible for participation in the standardized health insurance contracts established by (this §) ,regardless of any of the eligibility requirements established pursuant to subsection (this §)(c) . Source Data downloaded: 2009-04-09 15: 12: 49; Processed: 2009-05-08 15: 36: 10
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