N.Y. Insurance Law § 4235: Group accident and health insurance

§ 4235. Group accident and health insurance. (a) (1) Any policy of

insurance against death or injury resulting from an accident which

covers more than one person, except blanket accident insurance policies

as defined in section four thousand two hundred thirty-seven of this

article and accident and health insurance policies conforming to

subsections (a), (b) and (c) of section three thousand two hundred

sixteen of this chapter, shall be deemed a group accident insurance

policy.

(2) Any policy which insures against disablement, disease or sickness

(excluding disablement which results from accident), and which covers

more than one person, except blanket health insurance policies as

defined in section four thousand two hundred thirty-seven of this

article and accident and health insurance policies conforming to

subsections (a), (b) and (c) of section three thousand two hundred

sixteen of this chapter, shall be deemed a group health insurance

policy.

(3) Any policy of insurance which combines the coverage of group

accident insurance and of group health insurance shall be deemed a group

accident and health insurance policy.

(b) No policy of group accident, group health or group accident and

health insurance, and no certificate thereunder, shall be delivered or

issued for delivery in this state unless it conforms to the requirements

of section three thousand two hundred twenty-one of this chapter and

with the exception of a group policy or contract of insurance issued

pursuant to article nine of the workers' compensation law, unless it

conforms to the requirements of subsection (c) of this section.

(c) (1) No policy of group accident, group health or group accident

and health insurance shall be delivered or issued for delivery in this

state unless it conforms to one of the following descriptions:

(A) A policy issued to an employer or to a trustee or trustees of a

fund established by an employer, which employer or trustee or trustees

shall be deemed the policyholder, insuring with or without evidence of

insurability satisfactory to the insurer, employees of such employer,

and insuring, except as hereinafter provided, all of such employees or

all of any class or classes thereof determined by conditions pertaining

to the employment or a combination of such conditions and conditions

pertaining to the family status of the employee, for insurance coverage

on each person insured based upon some plan which will preclude

individual selection. However, such a plan may permit a limited number

of selections by employees if the selections offered utilize consistent

plans of coverage for individual group members so that the resulting

plans of coverage are reasonable. The premium for the policy shall be

paid by the policyholder, either from the employer's funds, or from

funds contributed by the insured employees, or from funds contributed

jointly by the employer and employees. If all or part of the premium is

to be derived from funds contributed by the insured employees, then such

policy must insure not less than fifty percent of such eligible

employees or, if less, fifty or more of such employees when such policy

is providing coverage for group hospital, medical, major medical or

similar comprehensive types of expense reimbursed insurance and, for all

other types of group accident and health insurance, must insure a

minimum of fifty percent or five of such eligible employees, whichever

is fewer.

(B) A policy issued to a trustee or trustees of a fund established by,

or participated in, by the employer members of a trade association,

which trustees shall be deemed the policyholder, for the sole benefit of

the employees of such employers, the policy must conform subject to the

following requirements:

(i) The policy may be issued only if:

(I) the association has been in existence for at least two years and

was formed for purposes principally other than obtaining insurance, and

(II) the participating employers, meaning such employer members whose

employees are to be insured, constitute at date of issue at least fifty

percent of the total employers eligible to participate, unless the total

number of persons covered at date of issue exceeds six hundred, in which

event such participating employers must constitute at least twenty-five

percent of such total employers, in either case omitting from

consideration any employer whose employees are already insured under a

similar group accident and health insurance policy.

(ii) The persons eligible for insurance under the policy shall be all

of the employees of the participating employers, or all of any class or

classes thereof determined by conditions pertaining to their employment.

(iii) The premium for the policy shall be paid by the trustee or

trustees either from funds contributed by the employers or by the

employees; or funds contributed jointly by the employers and the

employees. A policy on which no part of the premium so payable is to be

derived from funds contributed by the insured employees must insure all

eligible employees.

(iv) The policy must cover at least fifty employees at date of issue.

(v) The insurance coverage under the policy must be based upon some

plan precluding individual selection either by the employees or by the

policyholder or the employer. However, such a plan may permit a number

of selections by the employer if the selections offered utilize

consistent plans of coverage so the resulting plans of coverage are

reasonable. Furthermore, such a plan may permit a limited number of

selections by employees if the selections offered utilize consistent

plans of coverage for individual group members so that the resulting

plans of coverage are reasonable.

(C) A policy issued to a labor union, which shall be deemed the

policyholder, insuring, with or without evidence of insurability

satisfactory to the insurer, members of such union and insuring, except

as hereinafter provided all of such members or of any class or classes

thereof determined by conditions pertaining to their employment or

membership in the union or both for amounts of insurance on each person

insured based on a plan precluding individual selection, provided

however, such a plan may permit a limited number of selections by

members if the selections offered utilize consistent plans of coverage

for individual group members so that the resulting plans of coverage are

reasonable, and not less than fifty percent of all eligible union or, if

less, fifty or more of such eligible members are insured.

(D) A policy issued to a trustee or trustees of a fund established, or

participated in, by two or more employers or by one or more labor

unions, or by one or more employers and one or more labor unions, which

trustee or trustees shall be deemed the policyholder, to insure

employees of the employers or members of the unions for the benefit of

persons other than the employers or the unions, subject to the following

requirements:

(i) The persons eligible for insurance shall be all of the employees

of the employers or all of the members of the unions, or all of any

class or classes thereof determined by conditions pertaining to their

employment, or to membership in the unions, or to both.

(ii) The premium for the policy shall be paid by the trustee or

trustees either wholly from funds contributed by the employer or

employers of the insured person or by the union or unions, or by both,

or jointly from such funds and funds contributed by the insured persons

specifically for their insurance or from contributions by the insured

persons. A policy on which all or part of the premium is to be derived

from funds contributed by the insured persons specifically for their

insurance may be placed in force only if it insures not less than fifty

percent of the then eligible persons, or, if less, fifty or more of such

eligible persons excluding any as to whom evidence of individual

insurability is not satisfactory to the insurer. A policy on which no

part of the premium is to be derived from funds contributed by the

insured persons specifically for their insurance must insure all

eligible persons, excluding any as to whom evidence of individual

insurability is not satisfactory to the insurer.

(iii) The policy shall insure at least fifty persons at date of issue,

except that if part of the premium is to be derived from funds to be

contributed by the insured persons specifically for their insurance the

policy shall insure at least one hundred employees or members at date of

issue.

(iv) The insurance coverage under the policy shall be based upon some

plan precluding individual selection either by the insured persons or by

the policyholders, employers, or unions. However, with respect to a

policyholder, employer or union, such plan may permit a number of

selections by the policyholder, employer or union, if the selections

offered utilize consistent plans of coverage so that the resulting plans

of coverage are reasonable. Furthermore, such a plan may permit a

limited number of selections by insured persons if the selections

offered utilize consistent plans of coverage for individual group

members so that the resulting plans of coverage are reasonable.

(v) With respect to a policy issued to a trustee or trustees of a fund

established by one or more labor unions, or by one or more employers and

one or more labor unions the proposed insured must submit, and the

insurer must obtain, a written certification that a reasonable number of

comparative bids have been obtained from different insurers and that

such bids have been considered by the trustees before making a decision

concerning which bid to accept. Such decision must be made at a

trustees' meeting held on a date certain, and a copy of the minutes of

such meeting must be attached to such certification.

(E) A policy issued to a creditor, vendor, (including the parent

holding company of such creditor or vendor), trustee, trustees or agent

insuring a group of debtors or vendees, (including coverage on the

spouse of a debtor or vendee), all as defined and set forth in paragraph

three of subsection (b) of section four thousand two hundred sixteen of

this article and under the same conditions and limitations and subject

to the definitions as specified therein; provided, however, that the

amount of indemnity payable with respect to any person insured

thereunder shall not at any time exceed:

(i) in all cases except as hereinafter provided the lesser of thirty

thousand dollars and the amount of unpaid indebtedness due from or the

amount of the purchase price unpaid by such person;

(ii) in the case of a loan commitment pursuant to a program for

defraying the cost of attendance of a student at a college or university

or at an elementary or secondary school providing education required for

minors as described in said paragraph, the lesser of thirty thousand

dollars and the total of the unpaid balance of the scheduled periodic

payments whether due or not due and the amount of any outstanding loan

commitment pursuant to such a program; or

(iii) in the case of a transaction secured by a real estate mortgage,

the lesser of the sum of seventy-five thousand dollars and the amount of

the indebtedness so secured.

(F) A policy issued to a social services district pursuant to section

three hundred sixty-seven-a of the social services law.

(G) A policy issued to the state of New York insuring, with or without

evidence of individual insurability satisfactory to the insurer, persons

who are managerial or confidential employees, or retired managerial or

confidential employees, of governments or public employers for the

purposes of article fourteen of the civil service law. The state shall

be deemed to be the policyholder. With respect to its employees, the

state and each other participating government or public employer shall

be deemed to be the employer. The premiums on such policy may be paid by

the employer, by the employees, or by the employer and employees

jointly. If the premiums are derived from funds contributed wholly by

the employer, the policy must insure all eligible employees. If all or

part of the premium is to be derived from funds contributed by insured

employees, then such policy must insure not less than forty percent of

such employees, the calculation being with respect to each employer

individually. The insurance coverage may be based upon a plan which

permits a limited number of selections by the employees. The provisions

of subsections (d), (h), (i) and (j) hereof shall not apply to a policy

issued pursuant to this subparagraph.

(H) A policy issued to an association, or to a trustee or trustees of

a fund established, created or maintained for the benefit of members of

one or more associations, all of whose eligible members have the same

profession, trade or occupation, which association or associations have

been organized and maintained in good faith for purposes principally

other than that of obtaining insurance and have been in active existence

for at least two years. The policy shall insure members, or employees of

members, of such association or associations for the benefit of persons

other than employers and the association or associations, or any

officials, representatives, trustees or agents thereof and shall provide

for the issuance of a certificate to the persons insured or such

beneficiary as evidence of such insurance. The members or employees

eligible for the insurance under the policy shall be all the members, or

all the members and their employees, or all of any class or classes

thereof determined by conditions pertaining to their employment or to

association membership or both. The premiums for the policy shall be

paid from association or members' funds, or partly from such funds and

partly from funds contributed by the insured individuals, or from funds

wholly contributed by the insured individuals. A policy on which all or

part of the premium is to be derived from funds contributed by the

insured individuals specifically for their insurance must insure at

least fifty percent of the then eligible individuals or a minimum of two

hundred individuals, whichever is less, excluding any as to whom

evidence of individual insurability is not satisfactory to the insurer.

A policy on which no part of the premium is to be derived from funds

contributed by the insured individuals specifically for their insurance

must cover all eligible individuals, excluding any as to whom evidence

of individual insurability is not satisfactory to the insurer. In every

case the policy must cover at least one hundred individuals at date of

issue. The insurance coverage on employees insured under the policy

shall be based upon some plan precluding individual selection. However,

with respect to such fund, or association or associations, such a plan

may permit a number of selections by the fund, association or

associations if the selections offered utilize consistent plans of

coverage so that the resulting plans of coverage are reasonable.

Furthermore, such a plan may permit a limited number of selections

offered by employees or members if the selections offered utilize

consistent plans of coverage for individual group members so that the

resulting plans of coverage are reasonable. If a policy dividend is

declared or a reduction in rate is made under such a policy, the excess,

if any, of the aggregate dividends or rate reductions under the policy

over the aggregate expenditure for insurance under such policy made from

association or employer funds, including expenditures made in connection

with administration of such policy, shall be applied by the policyholder

for the sole benefit of the insured individuals. A policy issued

pursuant to this subparagraph shall provide a conversion privilege no

less favorable than that provided for in subsection (e) of section three

thousand two hundred twenty-one of this chapter.

(I) A policy insuring persons employed under 32 U.S.C. § 709, members

of the national guard on full-time training duty under title 32 of the

United States Code, or on active duty or active duty for training under

title 10 of the United States Code, under the full-time manning program,

issued to the adjutant general, who shall be deemed the policyholder, or

to a trustee or trustees of a fund established, created, or maintained

for the benefit of such individuals insured, which trustee or trustees

shall be deemed the policyholder, the premium of which is to be paid by

the individuals insured either directly or by deduction from wages or

salary. The policy must insure at least fifty percent or four hundred of

the individuals eligible for such insurance, whichever is less. Such

policy shall provide for the payment of benefits, to the individual

insured or to some beneficiary or beneficiaries other than to the

aforesaid trustees or the adjutant general. The policy shall also

provide for the issuance of a certificate of insurance to the individual

insured or to such beneficiary, as evidence of such insurance. The

insurance coverage may be based upon a plan which permits a limited

number of selections by the insured member, if the selections offered

utilize consistent plans of coverage so that the resulting plans of

coverage are reasonable.

(J) Under a policy issued by an insurer to a trustee or to the

trustees of a trust, established or adopted by two or more individuals

who are entitled to a right of conversion, pursuant to subsection (e) of

section three thousand two hundred twenty-one of this chapter or under

the terms of a contract covering residents of New York, which trustee or

trustees shall be deemed to be the policyholder, to insure such

individuals, subject to the following requirements:

(i) The policy must cover at least twenty-five individuals during the

first policy year.

(ii) The benefits provided under the policy shall be those required by

subsection (f), (g) or (h) of section three thousand two hundred

twenty-one of this chapter.

(iii) In lieu of the coverage requirements of subsections (k) and (l)

of section three thousand two hundred twenty-one of this chapter and

subparagraphs (B), (C), (D), (E) and (F) of paragraph four of subsection

(f) of this section, the coverage requirements of paragraphs one through

ten of subsection (i) and the requirements of subsection (j) of section

three thousand two hundred sixteen of this chapter shall be applicable

to such policy.

(iv) If a policy dividend is declared or a reduction in rate is made

under such a policy, it shall be applied by the policyholder for the

sole benefit of the insured individuals.

(K) A policy issued to an association or the trustee or trustees of a

trust established, or participated in, by one or more associations, to

insure association members, subject to the following:

(i) Each association shall have:

(I) A minimum of two hundred insured members at the policy's date of

issue;

(II) Been organized and maintained in good faith for purposes

principally other than that of obtaining insurance;

(III) Been in active existence for at least two years; and

(IV) A constitution and by-laws which provide that:

(aa) The association hold regular meetings not less than annually to

further the purposes of the association;

(bb) The association collect dues or solicit contributions from

members; and

(cc) The members have voting privileges and representation on the

governing board and committees.

(ii) The premium for the policy shall be paid by the association or

the trustees either wholly from funds contributed by the association or

by the insured individuals, or from funds contributed jointly by the

association and insured individuals. A policy on which no part of the

premium is to be derived from funds contributed by the insured

individuals specifically for their insurance must insure all eligible

individuals excluding any as to whom evidence of individual insurability

is not satisfactory to the insurer.

(iii) The amount of insurance under the policy shall be based upon

some plan precluding individual selection either by the insured members

or by the association. However, with respect to an association, such a

plan may permit a number of selections by the association if the

selections offered utilize consistent plans of insurance so that the

resulting plans of coverage are reasonable. Furthermore, such a plan may

permit a limited number of selections by insured members if the

selections offered utilize consistent plans of insurance for individual

group members so that the resulting plans of coverage are reasonable.

(iv) Except as provided in subsection (e) of this section, such policy

shall provide for the payment of benefits to the person insured or to

some beneficiary or beneficiaries other than the association or any

officials, representatives, trustees or agents thereof and shall provide

for the issuance of a certificate to the association for delivery to the

member or such beneficiary, as evidence of such insurance.

(v) The premiums charged must be reasonable in relation to the

benefits provided.

(L) A policy issued to any organization, or the trustee or trustees of

a trust established, or participated in, by one or more of such

organizations, to insure certain persons subject to the following:

(i) The organization must be:

(I) A bank, retailer or other issuer of a credit card, charge card or

payment card which can be used to buy goods or services, and the policy

must insure holders of that card;

(II) A bank, savings and loan association, credit union, mutual fund,

money market fund, stockbroker or other similar financial institution

regulated by state or federal law, and the policy must insure the

depositors, account holders or members of that institution.

(ii) Except for a credit union where the premium shall be paid

entirely from funds contributed by the credit union, the organization or

organizations shall have a minimum of two hundred insured persons at the

policy's date of issue.

(iii) The premium for the policy shall be paid by the organization or

trustees either wholly from funds contributed by the organization or by

the insured individuals, or from funds contributed jointly by the

organization and insured individuals. A policy on which no part of the

premium is to be derived from funds contributed by the insured

individuals specifically for their insurance must cover all eligible

individuals excluding any as to whom evidence of individual insurability

is not satisfactory to the insurer.

(iv) The amounts of insurance under the policy shall be based upon

some plan precluding individual selection either by the insured persons

or by the organization. However, with respect to an organization, such a

plan may permit a number of selections by the organization if the

selections offered utilize consistent plans of insurance so that the

resulting plans of coverage are reasonable. Furthermore, such a plan may

permit a limited number of selections by members if the selections

offered utilize consistent plans of grading the amounts of insurance for

individual group members so that the resulting plans of coverage are

reasonable.

(v) Except as provided in subsection (e) of this section, such policy

shall provide for the payment of benefits to the person insured or to

some beneficiary or beneficiaries other than the organization, or any

officials, representatives, trustees or agents thereof, and shall

provide for the issuance of a certificate to the persons insured or such

beneficiary, as evidence of such insurance.

(vi) The premium charged must be reasonable in relation to the

benefits provided.

(M) A policy issued to insure any other group approved by the

superintendent upon a finding that: (i) there is a common enterprise or

economic or social affinity or relationship; (ii) the premiums charged

are reasonable in relation to the benefits provided; and (iii) the

issuance of the policy would result in economies of acquisition or

administration, would be actuarially sound, and would not be contrary to

the best interest of the public. The superintendent shall promulgate

regulations setting forth any such groups that have been accepted as

qualifying pursuant to this subparagraph.

(N) A policy issued to a continuing care retirement community covering

at least fifty percent of the residents of the community, in conjunction

with a continuing care retirement contract described in section four

thousand six hundred one of the public health law.

(2) For the purpose of complying with the participation requirements

prescribed in subparagraphs (A), (B), (C), (D) and (G) of paragraph one

of this subsection, the provisions of this subsection are to be

construed as permitting the issuance of more than one policy or contract

when offered as alternatives to the eligible employees or members.

(3) (A) Any dividend hereafter apportioned on any participating group

insurance policy, or any rate reduction hereafter made or continued on

any non-participating group policy for the first or any subsequent year

of insurance under any such policy heretofore or hereafter issued under

subparagraph (K), (L) or (M) of paragraph one of this subsection, may be

applied to reduce the policyholder's part of the cost of such policy,

except that the excess, if any, of the insured's aggregate contribution

under the policy over the net cost (gross premium less dividends or rate

reductions) of the insurance shall be applied at the discretion of the

insurer either as a cash payment to the insured or to reduce the

insured's premium, unless the insured assigns the dividend or rate

reduction to the policyholder. If a dividend or rate reduction is

payable upon termination of the policy the insurer shall either make

payment to the insured or to the policyholder upon receipt of a

certification from the policyholder that the dividend or rate reduction

will be distributed by the policyholder to the insureds or applied to

reduce the insured's premium.

(B) The provisions of subparagraph (A) of this paragraph shall apply

to New York residents insured under a policy issued in any other

jurisdiction to a group which is not of the type described in

subparagraphs (A) through (J) of paragraph one of this subsection.

(d) (1) In this section, for the purpose of insurance other than for

group hospital, medical, major medical or similar comprehensive-types of

expense reimbursed insurance hereunder: "employees" includes the

officers, managers, employees and retired employees of the employer and

of subsidiary or affiliated corporations of a corporate employer, and

the individual proprietors, partners, employees and retired employees of

affiliated individuals and firms controlled by the insured employer

through stock ownership, contract or otherwise; "employees" may be

deemed to include the individual proprietor or partners if the employer

is an individual proprietor or a partnership; and "employees" as used in

subparagraph (A) of paragraph one of subsection (c) hereof may also

include the directors of the employer and of subsidiary or affiliated

corporations of a corporate employer.

(2) In this section "employer" may include any municipal corporation,

or the proper officers, as such, of any unincorporated municipality, or

any department of such corporation or municipality determined by

conditions pertaining to the employment.

(3) In this section, for the purpose of group hospital, medical, major

medical or similar comprehensive-types of expense reimbursed insurance

hereunder:

(A) "employee" shall have the meaning set forth in the Employee

Retirement Income Security Act of 1974, 29 U.S.C. § 1002(6); and

(B) "full-time employee" means with respect to any month, an employee

who is employed on average for at least thirty hours of service per week

as set forth in section 4980H(c)(4) of the internal revenue code, 26

U.S.C. § 4980H(c)(4), or any regulations promulgated thereunder.

(e) The benefits payable under the policy shall be payable to the

employee or other insured member of the group or to some beneficiary or

beneficiaries designated by him, other than the employer or the

association or any officer thereof as such; but if there is no

designated beneficiary as to all or any part of the insurance benefits

at the death of the employee or member, then the benefits payable for

which there is no designated beneficiary shall be payable to the estate

of the employee or member, except that the insurer may in such case, at

its option, pay such insurance to any one or more of the following

surviving relatives of the employee or member: wife, husband, mother,

father, child or children, brothers or sisters; and except that payment

of benefits for expenses incurred on account of hospitalization or

medical or surgical aid, may be made by the insurer to the hospital or

other person or persons furnishing such aid, and the payment of benefits

for expenses incurred on account of hospitalization or medical or

surgical aid after the death of an employee or other member of the

insured group for such person's spouse, child or children, or other

person chiefly dependent upon him for support or maintenance, may be

made by the insurer to the surviving spouse or otherwise as the policy

may provide. Payment so made shall discharge the insurer's obligation

with respect to the amount of insurance so paid.

(f) (1) (A) Any policy of group accident, group health or group

accident and health insurance may include provisions for the payment by

the insurer of benefits for expenses incurred on account of hospital,

medical or surgical care or physical and occupational therapy by

licensed physical and occupational therapists upon the prescription or

referral of a physician for the employee or other member of the insured

group, the employee's or member's spouse, the employee's or member's

child or children, or other persons chiefly dependent upon the employee

or member for support and maintenance; provided that:

(i) a policy of hospital, medical, surgical, or prescription drug

expense insurance that provides coverage for children shall provide such

coverage to a married or unmarried child until attainment of age

twenty-six, without regard to financial dependence, residency with the

employee or member, student status, or employment, except a policy that

is a grandfathered health plan may, for plan years beginning before

January first, two thousand fourteen, exclude coverage of an adult child

under age twenty-six who is eligible to enroll in an employer-sponsored

health plan other than a group health plan of a parent. For purposes of

this item, "grandfathered health plan" means coverage provided by an

insurer in which an individual was enrolled on March twenty-third, two

thousand ten for as long as the coverage maintains grandfathered status

in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.

§ 18011(e); and

(ii) a policy under which coverage terminates at a specified age shall

not so terminate with respect to an unmarried child who is incapable of

self-sustaining employment by reason of mental illness, developmental

disability, as defined in the mental hygiene law, or physical handicap

and who became so incapable prior to attainment of the age at which

coverage would otherwise terminate and who is chiefly dependent upon

such employee or member for support and maintenance, while the insurance

of the employee or member remains in force and the child remains in such

condition, if the insured employee or member has within thirty-one days

of such child's attainment of the termination age submitted proof of

such child's incapacity as described herein.

(B) In addition to the requirements of subparagraph (A) of this

paragraph, every insurer issuing a group policy of hospital, medical or

surgical expense insurance pursuant to this section that provides

coverage for children, must make available and if requested by the

policyholder, extend coverage under the policy to an unmarried child

through age twenty-nine, without regard to financial dependence who is

not insured by or eligible for coverage under any employer health

benefit plan as an employee or member, whether insured or self-insured,

and who lives, works or resides in New York state or the service area of

the insurer. Such coverage shall be made available at the inception of

all new policies and with respect to all other policies at any

anniversary date. Written notice of the availability of such coverage

shall be delivered to the policyholder prior to the inception of such

group policy and annually thereafter.

(2) Notwithstanding any rule, regulation or law to the contrary, any

family coverage available under this article 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 section one hundred fifteen-c of the domestic

relations law within thirty days of birth; and provided further that no

notice of revocation to the adoption has been filed pursuant to section

one hundred fifteen-b of the domestic relations law and consent to the

adoption has not been revoked, shall be effective from the moment of

birth for injury or sickness including the necessary care and treatment

of medically diagnosed congenital defects and birth abnormalities

including premature birth, except that in cases of adoption, coverage of

the initial hospital stay shall not be required where a birth parent has

insurance coverage available for the infant's care. In the case of

individual coverage the insurer 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 thirty 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 children.

(3) A policy under which coverage of a dependent spouse or named

insured would terminate upon such spouse or named insured attaining the

age prescribed in subchapter XVIII of the federal Social Security Act,

42 U.S.C. §§ 1395 et seq. ("Medicare"), as the age of first 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 policy 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 insurer within thirty-one days of

the date notice of termination of coverage be sent by first class mail

by the insurer to the last known address of the policyholder. Any such

policy may provide for the continuation of such benefit provisions, or

any part or parts thereof, after the exhaustion of the benefit rights

with respect to the employee or other member of the insured group, or

after the death of an active or retired employee or other member of the

insured group.

(4) Notwithstanding any provisions of a policy of group accident,

group health or group accident and health insurance, whenever such

policy provides for reimbursement for:

(A) any physical and occupational therapy service which is within the

lawful scope of practice of a licensed physical and occupational

therapist, a subscriber to such policy shall be entitled to

reimbursement for such service, whether the said service is performed by

a physician or licensed physical and occupational therapist pursuant to

prescription or referral by a physician;

(B) any podiatrical service which is within the lawful scope of

practice of a licensed podiatrist, a subscriber to such policy shall be

entitled to reimbursement for such service, whether the said service is

performed by a physician or licensed podiatrist and when such policy or

any certificate issued thereunder is delivered or issued for delivery

without this state by an authorized insurer, covered persons residing in

this state shall be entitled to reimbursement for podiatric services as

herein provided;

(C) any optometric service which is within the lawful scope of

practice of a licensed optometrist, a subscriber to such policy shall be

entitled to reimbursement for such service, whether the said service is

performed by a physician or licensed optometrist and when such policy or

any certificate issued thereunder or delivered or issued for delivery

without the state by an authorized insurer so provides, covered persons

residing in this state shall be entitled to reimbursement for that

service which may be rendered by an optometrist as herein provided.

Unless such policy shall otherwise provide, there shall be no

reimbursement for ophthalmic materials, lenses, spectacles, eyeglasses,

and/or appurtenances thereto;

(D) any dental service which is within the lawful scope of practice of

a licensed dentist, a subscriber to such policy shall be entitled to

reimbursement for such service whether the said service is performed by

a physician or licensed dentist and when such policy or any certificate

issued thereunder or delivered or issued for delivery without the state

by an authorized insurer so provides, covered persons residing in this

state shall be entitled to reimbursement for dental services as herein

provided;

(E) The services of licensed health professionals who can bill for

services, a subscriber to such policy shall be entitled to reimbursement

for such service provided pursuant to a clinical practice plan

established pursuant to subdivision fourteen of section two hundred six

of the public health law;

(F) any speech-language pathology or audiology service which is within

the lawful scope of practice of a duly licensed speech-language

pathologist or audiologist, a subscriber to such policy shall be

entitled to reimbursement for such service whether the said service is

performed by a physician or duly licensed speech-language pathologist or

audiologist, provided however, that nothing contained herein shall be

construed to impair any terms of such policy which may require said

service to be performed pursuant to a medical order, or a similar or

related service of a physician, in which case coverage need not be

provided for any tests, evaluations or diagnoses if such tests,

evaluations or diagnoses have already been provided by or through a

physician within twelve months of the referral or order from the

physician. However, nothing herein shall be construed as preventing an

insurer from covering more than one test or evaluation provided by a

speech-language pathologist or audiologist within a twelve-month period

where such test or evaluation is ordered by a physician as medically

necessary. Nor shall anything herein be construed as prohibiting the

limitation of such services, where covered, to specified settings other

than offices, such as hospitals or to services provided by such

professionals as part of a home care agency's services; and when such

policy or any certificate issued thereunder is delivered or issued for

delivery without the state by an authorized insurer, covered persons

residing in this state shall be entitled to reimbursement for

speech-language pathology or audiology service as herein provided.

(G) psychiatric or psychological services or for the diagnosis and

treatment of mental, nervous, or emotional disorders or ailments,

however defined in such policy, a subscriber to such policy shall be

entitled to reimbursement for such psychiatric or psychological services

or diagnosis or treatment whether performed by a physician, psychiatrist

or a certified and registered psychologist when the services rendered

are within the lawful scope of their practice, and when such policy or

any certificate issued thereunder is delivered or issued for delivery

without this state by an authorized insurer, covered persons residing in

this state shall be entitled to reimbursement for such diagnosis and

treatment by a physician, psychiatrist or a certified and registered

psychologist as hereinabove provided; and

(H) any service which is within the lawful scope of practice of a

licensed chiropractor, a subscriber to such policy shall be entitled to

reimbursement for such service when such service is performed by a

licensed chiropractor.

(g) (1) No domestic insurer and no foreign or alien insurer doing

business in this state shall hereafter issue, within or without this

state, any policy of group accident, group health or group accident and

health insurance, other than a policy issued pursuant to subparagraph

(J) of paragraph one of subsection (c) hereof, which shall not appear to

be self-supporting on reasonable assumptions as to morbidity or other

appropriate claim rate, interest and expense.

(2) The superintendent may require all such insurers to file with him,

either directly or through such agency as he may approve, at such times

and in such manner and for such forms of insurance as he prescribes,

their experience under such forms and such other information as the

superintendent may deem necessary or expedient for the administration of

this section and such experience and other information shall be compiled

and analyzed as the superintendent prescribes.

(h) (1) Each domestic insurer and each foreign or alien insurer doing

business in this state shall file with the superintendent its schedules

of premium rates, rules and classification of risks for use in

connection with the issuance of its policies of group accident, group

health or group accident and health insurance, and of its rates of

commissions, compensation or other fees or allowances to agents and

brokers pertaining to the solicitation or sale of such insurance and of

such fees or allowances, exclusive of amounts payable to persons who are

in the regular employ of the insurer, other than as agent or broker to

any individuals, firms or corporations pertaining to such class of

business, whether transacted within or without the state. A group

accident and health insurance policy providing disability and family

leave benefits pursuant to article nine of the workers' compensation law

shall be subject to the requirements of subsection (n) of this section.

(2) An insurer may revise such schedules from time to time, and shall

file such revised schedules with the superintendent.

(3) No insurer shall issue any policy of group accident, group health

or group accident and health insurance the premium rate under which for

the first policy year is less than that determined by the schedules of

such insurer as then on file with the superintendent; nor shall it pay

to the agent or agents or to a broker or brokers for the solicitation or

sale of such policy or for any other purpose related to such policy any

commission, compensation or other fees or allowances in excess of that

determined on the basis of the schedules of such insurer as then on file

with the superintendent; nor shall such insurer pay for services

pertaining to the service or administration thereof to any individual,

firm or corporation any fees, commissions or allowances in excess of

that determined on the basis of the schedules of such insurer as then on

file with the superintendent or for such services not rendered in behalf

of such insurer; provided, however, that nothing contained herein shall

apply to or affect the computation of dividends or experience rating

credits.

(4) Nothing herein shall prohibit the state insurance fund from taking

into account peculiar hazards of individual risks in establishing higher

premium rates to be charged for insurance providing for the payment of

disability and family leave benefits in accordance with article nine of

the workers' compensation law.

(i) (1) Whenever the superintendent determines, after notice to all

insurers doing the business of group accident, group health or group

accident and health insurance in this state and a hearing at which such

insurers may present pertinent statistics and other available data, that

it is advisable in the administration of this section to adopt a

schedule of minimum premium rates for any type of benefit provided under

policies of group accident, group health or group accident and health

insurance, the superintendent shall thereupon file in his office such a

schedule which shall include a description of the benefit or benefits

for which minimum premium rates are being prescribed and of the minimum

premium rates applicable thereto.

(2) Such schedule may be revised by the superintendent from time to

time or withdrawn, after a similar notice and hearing.

(3) The effective date of such schedule, or of any such revision or

withdrawal thereof, shall be specified by the superintendent. After the

effective date of the first schedule no domestic insurer and no foreign

or alien insurer doing business in this state shall issue, within or

without this state, any policy of group accident, group health or group

accident and health insurance providing any benefit to which the

schedule of minimum premium rates then in effect applies, unless the

premium for such benefit for the first policy year shall be at least

equal to that determined on the basis of such schedule.

(4) If an insurer desires to provide a benefit of the same general

type as, but not identical with, one described in said schedule, it

shall before issuing any policy providing for such different benefit

obtain the superintendent's approval of the premium proposed to be

charged therefor. The superintendent shall grant such approval if he is

satisfied that the proposed premium is not less than that which would

have to be charged consistent with the schedule of minimum premium rates

then in effect.

(j) (1) Anything in this chapter to the contrary notwithstanding, any

policy of group accident, group health or group accident and health

insurance may provide for readjustment of the rate of premium based on

the experience thereunder at the end of the first year or of any

subsequent year of insurance thereunder, and such readjustment may be

made retroactive only for such policy year.

(2) Any such rate readjustment shall be computed on a basis which is

equitable to all group accident, group health or group accident and

health insurance policies.

(3) Any refund under any plan for readjustment of the rate of premium

based on the experience under group policies and any dividend paid under

such policies may be used to reduce the employer's contribution to group

insurance for the employees of the employer, and the excess over such

contribution by the employer shall be applied by the employer for the

sole benefit of the employees.

(k) Whenever an insurer elects to terminate any policy as described in

this section, such insurer shall include in his notification of intent

to terminate such policy reference to the policyholder's

responsibilities under section two hundred seventeen of the labor law.

Whenever any policy as described in this section terminates as a result

of a default in payment of premiums, the insurer shall notify the

policyholder that termination has occurred or will occur and shall

include in his notification reference to the policyholder's

responsibilities under section two hundred seventeen of the labor law.

(l) The superintendent shall promulgate rules and regulations

concerning the method, manner and time for a policyholder to provide

written notice of termination to the certificate holders as required by

subdivision three of section two hundred seventeen of the labor law.

(m) This section shall not apply to any contract issued by any article

forty-three corporation except as provided in section four thousand

three hundred five of this chapter.

(n)(1) On or before June first, two thousand seventeen, the

superintendent of financial services by regulation, in consultation with

the chair of the workers' compensation board of this state, shall

determine whether the family leave benefit coverage of a group accident

and health insurance policy providing disability and family leave

benefits pursuant to article nine of the workers' compensation law,

including policies issued by the state insurance fund, shall be

experience rated or community rated, which may include subjecting the

family leave benefit coverage of the policy to a risk adjustment

mechanism. Notwithstanding any law to the contrary, the superintendent

shall establish the rates for any community rated family leave benefit

coverage and shall apply commonly accepted actuarial principles to

establish community rated family leave benefit coverage rates that are

not excessive, inadequate or unfairly discriminatory. On June first, two

thousand seventeen and on September first of each year thereafter the

superintendent shall publish all community rated family leave benefit

rates for the policy period beginning on the following January first.

(2) If the policy is subjected to a risk adjustment mechanism, the

superintendent of financial services shall promulgate regulations

necessary for the implementation of this subsection in consultation with

the chair of the workers' compensation board of this state. Any such

risk adjustment mechanism shall be administered directly by the

superintendent of financial services of this state, in consultation with

the chair of the workers' compensation board of this state, or by a

third party vendor selected by the superintendent of financial services

in consultation with the chair of the workers' compensation board.

(3) "Risk adjustment mechanism" as used in this subsection means the

process used to equalize the per member per month claim amounts among

insurers in order to protect insurers from disproportionate adverse

risks.

(o) (1) No contract or agreement between a health plan subject to this

article and a health care provider, other than a residential health care

facility as defined by section twenty-eight hundred one of the public

health law, shall include a provision that:

(A) contains a most-favored-nation provision; or

(B) restricts the ability of a corporation, an entity that contracts

with a corporation for a provider network, or a health care provider to

disclose: (i) actual claims costs; or (ii) price or quality information

required to be disclosed under federal law, including the allowed

amount, negotiated rates or discounts, or any other claim-related

financial obligations, including, but not limited to, patient

cost-sharing covered by the provider contract to any subscriber,

enrollee, group, or other entity receiving health care services pursuant

to the contract, or to any public compilation of reimbursement data such

as the New York all payer database required by law or regulation,

provided that no disclosure shall include protected health information

or other information covered by statutory or other privilege.

(2) For purposes of this subsection, the term "health plan" shall

include: (A) an insurer licensed pursuant to this chapter or a health

maintenance organization certified pursuant to article forty-four of the

public health law; and

(B) a third-party administrator, affiliated with an insurer or health

maintenance organization, who administers a health benefit plan.