§ 4235 — Group accident and health insurance

New York § 4235

• Jurisdiction: New York
• Law ISC: Insurance
• Art. 42: Life Insurance Companies and Accident and Health Insurance Companies and Legal Services Insurance Companies

Text

§ 4235. Group accident and health insurance. (a) (1) Any policy of\ninsurance against death or injury resulting from an accident which\ncovers more than one person, except blanket accident insurance policies\nas defined in section four thousand two hundred thirty-seven of this\narticle and accident and health insurance policies conforming to\nsubsections (a), (b) and (c) of section three thousand two hundred\nsixteen of this chapter, shall be deemed a group accident insurance\npolicy.\n (2) Any policy which insures against disablement, disease or sickness\n(excluding disablement which results from accident), and which covers\nmore than one person, except blanket health insurance policies as\ndefined in section four thousand two hundred thirty-seven of this\narticle and accident and health insurance policies conforming to\nsubsections (a), (b) and (c) of section three thousand two hundred\nsixteen of this chapter, shall be deemed a group health insurance\npolicy.\n (3) Any policy of insurance which combines the coverage of group\naccident insurance and of group health insurance shall be deemed a group\naccident and health insurance policy.\n (b) No policy of group accident, group health or group accident and\nhealth insurance, and no certificate thereunder, shall be delivered or\nissued for delivery in this state unless it conforms to the requirements\nof section three thousand two hundred twenty-one of this chapter and\nwith the exception of a group policy or contract of insurance issued\npursuant to article nine of the workers' compensation law, unless it\nconforms to the requirements of subsection (c) of this section.\n (c) (1) No policy of group accident, group health or group accident\nand health insurance shall be delivered or issued for delivery in this\nstate unless it conforms to one of the following descriptions:\n (A) A policy issued to an employer or to a trustee or trustees of a\nfund established by an employer, which employer or trustee or trustees\nshall be deemed the policyholder, insuring with or without evidence of\ninsurability satisfactory to the insurer, employees of such employer,\nand insuring, except as hereinafter provided, all of such employees or\nall of any class or classes thereof determined by conditions pertaining\nto the employment or a combination of such conditions and conditions\npertaining to the family status of the employee, for insurance coverage\non each person insured based upon some plan which will preclude\nindividual selection. However, such a plan may permit a limited number\nof selections by employees if the selections offered utilize consistent\nplans of coverage for individual group members so that the resulting\nplans of coverage are reasonable. The premium for the policy shall be\npaid by the policyholder, either from the employer's funds, or from\nfunds contributed by the insured employees, or from funds contributed\njointly by the employer and employees. If all or part of the premium is\nto be derived from funds contributed by the insured employees, then such\npolicy must insure not less than fifty percent of such eligible\nemployees or, if less, fifty or more of such employees when such policy\nis providing coverage for group hospital, medical, major medical or\nsimilar comprehensive types of expense reimbursed insurance and, for all\nother types of group accident and health insurance, must insure a\nminimum of fifty percent or five of such eligible employees, whichever\nis fewer.\n (B) A policy issued to a trustee or trustees of a fund established by,\nor participated in, by the employer members of a trade association,\nwhich trustees shall be deemed the policyholder, for the sole benefit of\nthe employees of such employers, the policy must conform subject to the\nfollowing requirements:\n (i) The policy may be issued only if:\n (I) the association has been in existence for at least two years and\nwas formed for purposes principally other than obtaining insurance, and\n (II) the participating employers, meaning such employer members whose\nemployees are to be insured, constitute at date of issue at least fifty\npercent of the total employers eligible to participate, unless the total\nnumber of persons covered at date of issue exceeds six hundred, in which\nevent such participating employers must constitute at least twenty-five\npercent of such total employers, in either case omitting from\nconsideration any employer whose employees are already insured under a\nsimilar group accident and health insurance policy.\n (ii) The persons eligible for insurance under the policy shall be all\nof the employees of the participating employers, or all of any class or\nclasses thereof determined by conditions pertaining to their employment.\n (iii) The premium for the policy shall be paid by the trustee or\ntrustees either from funds contributed by the employers or by the\nemployees; or funds contributed jointly by the employers and the\nemployees. A policy on which no part of the premium so payable is to be\nderived from funds contributed by the insured employees must insure all\neligible employees.\n (iv) The policy must cover at least fifty employees at date of issue.\n (v) The insurance coverage under the policy must be based upon some\nplan precluding individual selection either by the employees or by the\npolicyholder or the employer. However, such a plan may permit a number\nof selections by the employer if the selections offered utilize\nconsistent plans of coverage so the resulting plans of coverage are\nreasonable. Furthermore, such a plan may permit a limited number of\nselections by employees if the selections offered utilize consistent\nplans of coverage for individual group members so that the resulting\nplans of coverage are reasonable.\n (C) A policy issued to a labor union, which shall be deemed the\npolicyholder, insuring, with or without evidence of insurability\nsatisfactory to the insurer, members of such union and insuring, except\nas hereinafter provided all of such members or of any class or classes\nthereof determined by conditions pertaining to their employment or\nmembership in the union or both for amounts of insurance on each person\ninsured based on a plan precluding individual selection, provided\nhowever, such a plan may permit a limited number of selections by\nmembers if the selections offered utilize consistent plans of coverage\nfor individual group members so that the resulting plans of coverage are\nreasonable, and not less than fifty percent of all eligible union or, if\nless, fifty or more of such eligible members are insured.\n (D) A policy issued to a trustee or trustees of a fund established, or\nparticipated in, by two or more employers or by one or more labor\nunions, or by one or more employers and one or more labor unions, which\ntrustee or trustees shall be deemed the policyholder, to insure\nemployees of the employers or members of the unions for the benefit of\npersons other than the employers or the unions, subject to the following\nrequirements:\n (i) The persons eligible for insurance shall be all of the employees\nof the employers or all of the members of the unions, or all of any\nclass or classes thereof determined by conditions pertaining to their\nemployment, or to membership in the unions, or to both.\n (ii) The premium for the policy shall be paid by the trustee or\ntrustees either wholly from funds contributed by the employer or\nemployers of the insured person or by the union or unions, or by both,\nor jointly from such funds and funds contributed by the insured persons\nspecifically for their insurance or from contributions by the insured\npersons. A policy on which all or part of the premium is to be derived\nfrom funds contributed by the insured persons specifically for their\ninsurance may be placed in force only if it insures not less than fifty\npercent of the then eligible persons, or, if less, fifty or more of such\neligible persons excluding any as to whom evidence of individual\ninsurability is not satisfactory to the insurer. A policy on which no\npart of the premium is to be derived from funds contributed by the\ninsured persons specifically for their insurance must insure all\neligible persons, excluding any as to whom evidence of individual\ninsurability is not satisfactory to the insurer.\n (iii) The policy shall insure at least fifty persons at date of issue,\nexcept that if part of the premium is to be derived from funds to be\ncontributed by the insured persons specifically for their insurance the\npolicy shall insure at least one hundred employees or members at date of\nissue.\n (iv) The insurance coverage under the policy shall be based upon some\nplan precluding individual selection either by the insured persons or by\nthe policyholders, employers, or unions. However, with respect to a\npolicyholder, employer or union, such plan may permit a number of\nselections by the policyholder, employer or union, if the selections\noffered utilize consistent plans of coverage so that the resulting plans\nof coverage are reasonable. Furthermore, such a plan may permit a\nlimited number of selections by insured persons if the selections\noffered utilize consistent plans of coverage for individual group\nmembers so that the resulting plans of coverage are reasonable.\n (v) With respect to a policy issued to a trustee or trustees of a fund\nestablished by one or more labor unions, or by one or more employers and\none or more labor unions the proposed insured must submit, and the\ninsurer must obtain, a written certification that a reasonable number of\ncomparative bids have been obtained from different insurers and that\nsuch bids have been considered by the trustees before making a decision\nconcerning which bid to accept. Such decision must be made at a\ntrustees' meeting held on a date certain, and a copy of the minutes of\nsuch meeting must be attached to such certification.\n (E) A policy issued to a creditor, vendor, (including the parent\nholding company of such creditor or vendor), trustee, trustees or agent\ninsuring a group of debtors or vendees, (including coverage on the\nspouse of a debtor or vendee), all as defined and set forth in paragraph\nthree of subsection (b) of section four thousand two hundred sixteen of\nthis article and under the same conditions and limitations and subject\nto the definitions as specified therein; provided, however, that the\namount of indemnity payable with respect to any person insured\nthereunder shall not at any time exceed:\n (i) in all cases except as hereinafter provided the lesser of thirty\nthousand dollars and the amount of unpaid indebtedness due from or the\namount of the purchase price unpaid by such person;\n (ii) in the case of a loan commitment pursuant to a program for\ndefraying the cost of attendance of a student at a college or university\nor at an elementary or secondary school providing education required for\nminors as described in said paragraph, the lesser of thirty thousand\ndollars and the total of the unpaid balance of the scheduled periodic\npayments whether due or not due and the amount of any outstanding loan\ncommitment pursuant to such a program; or\n (iii) in the case of a transaction secured by a real estate mortgage,\nthe lesser of the sum of seventy-five thousand dollars and the amount of\nthe indebtedness so secured.\n (F) A policy issued to a social services district pursuant to section\nthree hundred sixty-seven-a of the social services law.\n (G) A policy issued to the state of New York insuring, with or without\nevidence of individual insurability satisfactory to the insurer, persons\nwho are managerial or confidential employees, or retired managerial or\nconfidential employees, of governments or public employers for the\npurposes of article fourteen of the civil service law. The state shall\nbe deemed to be the policyholder. With respect to its employees, the\nstate and each other participating government or public employer shall\nbe deemed to be the employer. The premiums on such policy may be paid by\nthe employer, by the employees, or by the employer and employees\njointly. If the premiums are derived from funds contributed wholly by\nthe employer, the policy must insure all eligible employees. If all or\npart of the premium is to be derived from funds contributed by insured\nemployees, then such policy must insure not less than forty percent of\nsuch employees, the calculation being with respect to each employer\nindividually. The insurance coverage may be based upon a plan which\npermits a limited number of selections by the employees. The provisions\nof subsections (d), (h), (i) and (j) hereof shall not apply to a policy\nissued pursuant to this subparagraph.\n (H) A policy issued to an association, or to a trustee or trustees of\na fund established, created or maintained for the benefit of members of\none or more associations, all of whose eligible members have the same\nprofession, trade or occupation, which association or associations have\nbeen organized and maintained in good faith for purposes principally\nother than that of obtaining insurance and have been in active existence\nfor at least two years. The policy shall insure members, or employees of\nmembers, of such association or associations for the benefit of persons\nother than employers and the association or associations, or any\nofficials, representatives, trustees or agents thereof and shall provide\nfor the issuance of a certificate to the persons insured or such\nbeneficiary as evidence of such insurance. The members or employees\neligible for the insurance under the policy shall be all the members, or\nall the members and their employees, or all of any class or classes\nthereof determined by conditions pertaining to their employment or to\nassociation membership or both. The premiums for the policy shall be\npaid from association or members' funds, or partly from such funds and\npartly from funds contributed by the insured individuals, or from funds\nwholly contributed by the insured individuals. A policy on which all or\npart of the premium is to be derived from funds contributed by the\ninsured individuals specifically for their insurance must insure at\nleast fifty percent of the then eligible individuals or a minimum of two\nhundred individuals, whichever is less, excluding any as to whom\nevidence of individual insurability is not satisfactory to the insurer.\nA policy on which no part of the premium is to be derived from funds\ncontributed by the insured individuals specifically for their insurance\nmust cover all eligible individuals, excluding any as to whom evidence\nof individual insurability is not satisfactory to the insurer. In every\ncase the policy must cover at least one hundred individuals at date of\nissue. The insurance coverage on employees insured under the policy\nshall be based upon some plan precluding individual selection. However,\nwith respect to such fund, or association or associations, such a plan\nmay permit a number of selections by the fund, association or\nassociations if the selections offered utilize consistent plans of\ncoverage so that the resulting plans of coverage are reasonable.\nFurthermore, such a plan may permit a limited number of selections\noffered by employees or members if the selections offered utilize\nconsistent plans of coverage for individual group members so that the\nresulting plans of coverage are reasonable. If a policy dividend is\ndeclared or a reduction in rate is made under such a policy, the excess,\nif any, of the aggregate dividends or rate reductions under the policy\nover the aggregate expenditure for insurance under such policy made from\nassociation or employer funds, including expenditures made in connection\nwith administration of such policy, shall be applied by the policyholder\nfor the sole benefit of the insured individuals. A policy issued\npursuant to this subparagraph shall provide a conversion privilege no\nless favorable than that provided for in subsection (e) of section three\nthousand two hundred twenty-one of this chapter.\n (I) A policy insuring persons employed under 32 U.S.C. § 709, members\nof the national guard on full-time training duty under title 32 of the\nUnited States Code, or on active duty or active duty for training under\ntitle 10 of the United States Code, under the full-time manning program,\nissued to the adjutant general, who shall be deemed the policyholder, or\nto a trustee or trustees of a fund established, created, or maintained\nfor the benefit of such individuals insured, which trustee or trustees\nshall be deemed the policyholder, the premium of which is to be paid by\nthe individuals insured either directly or by deduction from wages or\nsalary. The policy must insure at least fifty percent or four hundred of\nthe individuals eligible for such insurance, whichever is less. Such\npolicy shall provide for the payment of benefits, to the individual\ninsured or to some beneficiary or beneficiaries other than to the\naforesaid trustees or the adjutant general. The policy shall also\nprovide for the issuance of a certificate of insurance to the individual\ninsured or to such beneficiary, as evidence of such insurance. The\ninsurance coverage may be based upon a plan which permits a limited\nnumber of selections by the insured member, if the selections offered\nutilize consistent plans of coverage so that the resulting plans of\ncoverage are reasonable.\n (J) Under a policy issued by an insurer to a trustee or to the\ntrustees of a trust, established or adopted by two or more individuals\nwho are entitled to a right of conversion, pursuant to subsection (e) of\nsection three thousand two hundred twenty-one of this chapter or under\nthe terms of a contract covering residents of New York, which trustee or\ntrustees shall be deemed to be the policyholder, to insure such\nindividuals, subject to the following requirements:\n (i) The policy must cover at least twenty-five individuals during the\nfirst policy year.\n (ii) The benefits provided under the policy shall be those required by\nsubsection (f), (g) or (h) of section three thousand two hundred\ntwenty-one of this chapter.\n (iii) In lieu of the coverage requirements of subsections (k) and (l)\nof section three thousand two hundred twenty-one of this chapter and\nsubparagraphs (B), (C), (D), (E) and (F) of paragraph four of subsection\n(f) of this section, the coverage requirements of paragraphs one through\nten of subsection (i) and the requirements of subsection (j) of section\nthree thousand two hundred sixteen of this chapter shall be applicable\nto such policy.\n (iv) If a policy dividend is declared or a reduction in rate is made\nunder such a policy, it shall be applied by the policyholder for the\nsole benefit of the insured individuals.\n (K) A policy issued to an association or the trustee or trustees of a\ntrust established, or participated in, by one or more associations, to\ninsure association members, subject to the following:\n (i) Each association shall have:\n (I) A minimum of two hundred insured members at the policy's date of\nissue;\n (II) Been organized and maintained in good faith for purposes\nprincipally other than that of obtaining insurance;\n (III) Been in active existence for at least two years; and\n (IV) A constitution and by-laws which provide that:\n (aa) The association hold regular meetings not less than annually to\nfurther the purposes of the association;\n (bb) The association collect dues or solicit contributions from\nmembers; and\n (cc) The members have voting privileges and representation on the\ngoverning board and committees.\n (ii) The premium for the policy shall be paid by the association or\nthe trustees either wholly from funds contributed by the association or\nby the insured individuals, or from funds contributed jointly by the\nassociation and insured individuals. A policy on which no part of the\npremium is to be derived from funds contributed by the insured\nindividuals specifically for their insurance must insure all eligible\nindividuals excluding any as to whom evidence of individual insurability\nis not satisfactory to the insurer.\n (iii) The amount of insurance under the policy shall be based upon\nsome plan precluding individual selection either by the insured members\nor by the association. However, with respect to an association, such a\nplan may permit a number of selections by the association if the\nselections offered utilize consistent plans of insurance so that the\nresulting plans of coverage are reasonable. Furthermore, such a plan may\npermit a limited number of selections by insured members if the\nselections offered utilize consistent plans of insurance for individual\ngroup members so that the resulting plans of coverage are reasonable.\n (iv) Except as provided in subsection (e) of this section, such policy\nshall provide for the payment of benefits to the person insured or to\nsome beneficiary or beneficiaries other than the association or any\nofficials, representatives, trustees or agents thereof and shall provide\nfor the issuance of a certificate to the association for delivery to the\nmember or such beneficiary, as evidence of such insurance.\n (v) The premiums charged must be reasonable in relation to the\nbenefits provided.\n (L) A policy issued to any organization, or the trustee or trustees of\na trust established, or participated in, by one or more of such\norganizations, to insure certain persons subject to the following:\n (i) The organization must be:\n (I) A bank, retailer or other issuer of a credit card, charge card or\npayment card which can be used to buy goods or services, and the policy\nmust insure holders of that card;\n (II) A bank, savings and loan association, credit union, mutual fund,\nmoney market fund, stockbroker or other similar financial institution\nregulated by state or federal law, and the policy must insure the\ndepositors, account holders or members of that institution.\n (ii) Except for a credit union where the premium shall be paid\nentirely from funds contributed by the credit union, the organization or\norganizations shall have a minimum of two hundred insured persons at the\npolicy's date of issue.\n (iii) The premium for the policy shall be paid by the organization or\ntrustees either wholly from funds contributed by the organization or by\nthe insured individuals, or from funds contributed jointly by the\norganization and insured individuals. A policy on which no part of the\npremium is to be derived from funds contributed by the insured\nindividuals specifically for their insurance must cover all eligible\nindividuals excluding any as to whom evidence of individual insurability\nis not satisfactory to the insurer.\n (iv) The amounts of insurance under the policy shall be based upon\nsome plan precluding individual selection either by the insured persons\nor by the organization. However, with respect to an organization, such a\nplan may permit a number of selections by the organization if the\nselections offered utilize consistent plans of insurance so that the\nresulting plans of coverage are reasonable. Furthermore, such a plan may\npermit a limited number of selections by members if the selections\noffered utilize consistent plans of grading the amounts of insurance for\nindividual group members so that the resulting plans of coverage are\nreasonable.\n (v) Except as provided in subsection (e) of this section, such policy\nshall provide for the payment of benefits to the person insured or to\nsome beneficiary or beneficiaries other than the organization, or any\nofficials, representatives, trustees or agents thereof, and shall\nprovide for the issuance of a certificate to the persons insured or such\nbeneficiary, as evidence of such insurance.\n (vi) The premium charged must be reasonable in relation to the\nbenefits provided.\n (M) A policy issued to insure any other group approved by the\nsuperintendent upon a finding that: (i) there is a common enterprise or\neconomic or social affinity or relationship; (ii) the premiums charged\nare reasonable in relation to the benefits provided; and (iii) the\nissuance of the policy would result in economies of acquisition or\nadministration, would be actuarially sound, and would not be contrary to\nthe best interest of the public. The superintendent shall promulgate\nregulations setting forth any such groups that have been accepted as\nqualifying pursuant to this subparagraph.\n (N) A policy issued to a continuing care retirement community covering\nat least fifty percent of the residents of the community, in conjunction\nwith a continuing care retirement contract described in section four\nthousand six hundred one of the public health law.\n (2) For the purpose of complying with the participation requirements\nprescribed in subparagraphs (A), (B), (C), (D) and (G) of paragraph one\nof this subsection, the provisions of this subsection are to be\nconstrued as permitting the issuance of more than one policy or contract\nwhen offered as alternatives to the eligible employees or members.\n (3) (A) Any dividend hereafter apportioned on any participating group\ninsurance policy, or any rate reduction hereafter made or continued on\nany non-participating group policy for the first or any subsequent year\nof insurance under any such policy heretofore or hereafter issued under\nsubparagraph (K), (L) or (M) of paragraph one of this subsection, may be\napplied to reduce the policyholder's part of the cost of such policy,\nexcept that the excess, if any, of the insured's aggregate contribution\nunder the policy over the net cost (gross premium less dividends or rate\nreductions) of the insurance shall be applied at the discretion of the\ninsurer either as a cash payment to the insured or to reduce the\ninsured's premium, unless the insured assigns the dividend or rate\nreduction to the policyholder. If a dividend or rate reduction is\npayable upon termination of the policy the insurer shall either make\npayment to the insured or to the policyholder upon receipt of a\ncertification from the policyholder that the dividend or rate reduction\nwill be distributed by the policyholder to the insureds or applied to\nreduce the insured's premium.\n (B) The provisions of subparagraph (A) of this paragraph shall apply\nto New York residents insured under a policy issued in any other\njurisdiction to a group which is not of the type described in\nsubparagraphs (A) through (J) of paragraph one of this subsection.\n (d) (1) In this section, for the purpose of insurance other than for\ngroup hospital, medical, major medical or similar comprehensive-types of\nexpense reimbursed insurance hereunder: "employees" includes the\nofficers, managers, employees and retired employees of the employer and\nof subsidiary or affiliated corporations of a corporate employer, and\nthe individual proprietors, partners, employees and retired employees of\naffiliated individuals and firms controlled by the insured employer\nthrough stock ownership, contract or otherwise; "employees" may be\ndeemed to include the individual proprietor or partners if the employer\nis an individual proprietor or a partnership; and "employees" as used in\nsubparagraph (A) of paragraph one of subsection (c) hereof may also\ninclude the directors of the employer and of subsidiary or affiliated\ncorporations of a corporate employer.\n (2) In this section "employer" may include any municipal corporation,\nor the proper officers, as such, of any unincorporated municipality, or\nany department of such corporation or municipality determined by\nconditions pertaining to the employment.\n (3) In this section, for the purpose of group hospital, medical, major\nmedical or similar comprehensive-types of expense reimbursed insurance\nhereunder:\n (A) "employee" shall have the meaning set forth in the Employee\nRetirement Income Security Act of 1974, 29 U.S.C. § 1002(6); and\n (B) "full-time employee" means with respect to any month, an employee\nwho is employed on average for at least thirty hours of service per week\nas set forth in section 4980H(c)(4) of the internal revenue code, 26\nU.S.C. § 4980H(c)(4), or any regulations promulgated thereunder.\n (e) The benefits payable under the policy shall be payable to the\nemployee or other insured member of the group or to some beneficiary or\nbeneficiaries designated by him, other than the employer or the\nassociation or any officer thereof as such; but if there is no\ndesignated beneficiary as to all or any part of the insurance benefits\nat the death of the employee or member, then the benefits payable for\nwhich there is no designated beneficiary shall be payable to the estate\nof the employee or member, except that the insurer may in such case, at\nits option, pay such insurance to any one or more of the following\nsurviving relatives of the employee or member: wife, husband, mother,\nfather, child or children, brothers or sisters; and except that payment\nof benefits for expenses incurred on account of hospitalization or\nmedical or surgical aid, may be made by the insurer to the hospital or\nother person or persons furnishing such aid, and the payment of benefits\nfor expenses incurred on account of hospitalization or medical or\nsurgical aid after the death of an employee or other member of the\ninsured group for such person's spouse, child or children, or other\nperson chiefly dependent upon him for support or maintenance, may be\nmade by the insurer to the surviving spouse or otherwise as the policy\nmay provide. Payment so made shall discharge the insurer's obligation\nwith respect to the amount of insurance so paid.\n (f) (1) (A) Any policy of group accident, group health or group\naccident and health insurance may include provisions for the payment by\nthe insurer of benefits for expenses incurred on account of hospital,\nmedical or surgical care or physical and occupational therapy by\nlicensed physical and occupational therapists upon the prescription or\nreferral of a physician for the employee or other member of the insured\ngroup, the employee's or member's spouse, the employee's or member's\nchild or children, or other persons chiefly dependent upon the employee\nor member for support and maintenance; provided that:\n (i) a policy of hospital, medical, surgical, or prescription drug\nexpense insurance that provides coverage for children shall provide such\ncoverage to a married or unmarried child until attainment of age\ntwenty-six, without regard to financial dependence, residency with the\nemployee or member, student status, or employment, except a policy that\nis a grandfathered health plan may, for plan years beginning before\nJanuary first, two thousand fourteen, exclude coverage of an adult child\nunder age twenty-six who is eligible to enroll in an employer-sponsored\nhealth plan other than a group health plan of a parent. For purposes of\nthis item, "grandfathered health plan" means coverage provided by an\ninsurer in which an individual was enrolled on March twenty-third, two\nthousand ten for as long as the coverage maintains grandfathered status\nin accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.\n§ 18011(e); and\n (ii) a policy under which coverage terminates at a specified age shall\nnot so terminate with respect to an unmarried child who is incapable of\nself-sustaining employment by reason of mental illness, developmental\ndisability, as defined in the mental hygiene law, or physical handicap\nand who became so incapable prior to attainment of the age at which\ncoverage would otherwise terminate and who is chiefly dependent upon\nsuch employee or member for support and maintenance, while the insurance\nof the employee or member remains in force and the child remains in such\ncondition, if the insured employee or member has within thirty-one days\nof such child's attainment of the termination age submitted proof of\nsuch child's incapacity as described herein.\n (B) In addition to the requirements of subparagraph (A) of this\nparagraph, every insurer issuing a group policy of hospital, medical or\nsurgical expense insurance pursuant to this section that provides\ncoverage for children, must make available and if requested by the\npolicyholder, extend coverage under the policy to an unmarried child\nthrough age twenty-nine, without regard to financial dependence who is\nnot insured by or eligible for coverage under any employer health\nbenefit plan as an employee or member, whether insured or self-insured,\nand who lives, works or resides in New York state or the service area of\nthe insurer. Such coverage shall be made available at the inception of\nall new policies and with respect to all other policies at any\nanniversary date. Written notice of the availability of such coverage\nshall be delivered to the policyholder prior to the inception of such\ngroup policy and annually thereafter.\n (2) Notwithstanding any rule, regulation or law to the contrary, any\nfamily coverage available under this article shall provide that coverage\nof newborn infants, including newly born infants adopted by the insured\nor subscriber if such insured or subscriber takes physical custody of\nthe infant upon such infant's release from the hospital and files a\npetition pursuant to section one hundred fifteen-c of the domestic\nrelations law within thirty days of birth; and provided further that no\nnotice of revocation to the adoption has been filed pursuant to section\none hundred fifteen-b of the domestic relations law and consent to the\nadoption has not been revoked, shall be effective from the moment of\nbirth for injury or sickness including the necessary care and treatment\nof medically diagnosed congenital defects and birth abnormalities\nincluding premature birth, except that in cases of adoption, coverage of\nthe initial hospital stay shall not be required where a birth parent has\ninsurance coverage available for the infant's care. In the case of\nindividual coverage the insurer must also permit the person to whom the\ncertificate is issued to elect such coverage of newborn infants from the\nmoment of birth. If notification and/or payment of an additional premium\nor contribution is required to make coverage effective for a newborn\ninfant, the coverage may provide that such notice and/or payment be made\nwithin no less than thirty days of the day of birth to make coverage\neffective from the moment of birth. This election shall not be required\nin the case of student insurance or where the group's plan does not\nprovide coverage for children.\n (3) A policy under which coverage of a dependent spouse or named\ninsured would terminate upon such spouse or named insured attaining the\nage prescribed in subchapter XVIII of the federal Social Security Act,\n42 U.S.C. §§ 1395 et seq. ("Medicare"), as the age of first eligibility\nfor the benefits provided by such law shall not so terminate, if such\ndependent spouse is not then eligible for all of such benefits for as\nlong as the policy remains in force and such dependent spouse remains\nineligible to receive any of such "Medicare" benefits, provided proof of\nsuch ineligibility is submitted to the insurer within thirty-one days of\nthe date notice of termination of coverage be sent by first class mail\nby the insurer to the last known address of the policyholder. Any such\npolicy may provide for the continuation of such benefit provisions, or\nany part or parts thereof, after the exhaustion of the benefit rights\nwith respect to the employee or other member of the insured group, or\nafter the death of an active or retired employee or other member of the\ninsured group.\n (4) Notwithstanding any provisions of a policy of group accident,\ngroup health or group accident and health insurance, whenever such\npolicy provides for reimbursement for:\n (A) any physical and occupational therapy service which is within the\nlawful scope of practice of a licensed physical and occupational\ntherapist, a subscriber to such policy shall be entitled to\nreimbursement for such service, whether the said service is performed by\na physician or licensed physical and occupational therapist pursuant to\nprescription or referral by a physician;\n (B) any podiatrical service which is within the lawful scope of\npractice of a licensed podiatrist, a subscriber to such policy shall be\nentitled to reimbursement for such service, whether the said service is\nperformed by a physician or licensed podiatrist and when such policy or\nany certificate issued thereunder is delivered or issued for delivery\nwithout this state by an authorized insurer, covered persons residing in\nthis state shall be entitled to reimbursement for podiatric services as\nherein provided;\n (C) any optometric service which is within the lawful scope of\npractice of a licensed optometrist, a subscriber to such policy shall be\nentitled to reimbursement for such service, whether the said service is\nperformed by a physician or licensed optometrist and when such policy or\nany certificate issued thereunder or delivered or issued for delivery\nwithout the state by an authorized insurer so provides, covered persons\nresiding in this state shall be entitled to reimbursement for that\nservice which may be rendered by an optometrist as herein provided.\nUnless such policy shall otherwise provide, there shall be no\nreimbursement for ophthalmic materials, lenses, spectacles, eyeglasses,\nand/or appurtenances thereto;\n (D) any dental service which is within the lawful scope of practice of\na licensed dentist, a subscriber to such policy shall be entitled to\nreimbursement for such service whether the said service is performed by\na physician or licensed dentist and when such policy or any certificate\nissued thereunder or delivered or issued for delivery without the state\nby an authorized insurer so provides, covered persons residing in this\nstate shall be entitled to reimbursement for dental services as herein\nprovided;\n (E) The services of licensed health professionals who can bill for\nservices, a subscriber to such policy shall be entitled to reimbursement\nfor such service provided pursuant to a clinical practice plan\nestablished pursuant to subdivision fourteen of section two hundred six\nof the public health law;\n (F) any speech-language pathology or audiology service which is within\nthe lawful scope of practice of a duly licensed speech-language\npathologist or audiologist, a subscriber to such policy shall be\nentitled to reimbursement for such service whether the said service is\nperformed by a physician or duly licensed speech-language pathologist or\naudiologist, provided however, that nothing contained herein shall be\nconstrued to impair any terms of such policy which may require said\nservice to be performed pursuant to a medical order, or a similar or\nrelated service of a physician, in which case coverage need not be\nprovided for any tests, evaluations or diagnoses if such tests,\nevaluations or diagnoses have already been provided by or through a\nphysician within twelve months of the referral or order from the\nphysician. However, nothing herein shall be construed as preventing an\ninsurer from covering more than one test or evaluation provided by a\nspeech-language pathologist or audiologist within a twelve-month period\nwhere such test or evaluation is ordered by a physician as medically\nnecessary. Nor shall anything herein be construed as prohibiting the\nlimitation of such services, where covered, to specified settings other\nthan offices, such as hospitals or to services provided by such\nprofessionals as part of a home care agency's services; and when such\npolicy or any certificate issued thereunder is delivered or issued for\ndelivery without the state by an authorized insurer, covered persons\nresiding in this state shall be entitled to reimbursement for\nspeech-language pathology or audiology service as herein provided.\n (G) psychiatric or psychological services or for the diagnosis and\ntreatment of mental, nervous, or emotional disorders or ailments,\nhowever defined in such policy, a subscriber to such policy shall be\nentitled to reimbursement for such psychiatric or psychological services\nor diagnosis or treatment whether performed by a physician, psychiatrist\nor a certified and registered psychologist when the services rendered\nare within the lawful scope of their practice, and when such policy or\nany certificate issued thereunder is delivered or issued for delivery\nwithout this state by an authorized insurer, covered persons residing in\nthis state shall be entitled to reimbursement for such diagnosis and\ntreatment by a physician, psychiatrist or a certified and registered\npsychologist as hereinabove provided; and\n (H) any service which is within the lawful scope of practice of a\nlicensed chiropractor, a subscriber to such policy shall be entitled to\nreimbursement for such service when such service is performed by a\nlicensed chiropractor.\n (g) (1) No domestic insurer and no foreign or alien insurer doing\nbusiness in this state shall hereafter issue, within or without this\nstate, any policy of group accident, group health or group accident and\nhealth insurance, other than a policy issued pursuant to subparagraph\n(J) of paragraph one of subsection (c) hereof, which shall not appear to\nbe self-supporting on reasonable assumptions as to morbidity or other\nappropriate claim rate, interest and expense.\n (2) The superintendent may require all such insurers to file with him,\neither directly or through such agency as he may approve, at such times\nand in such manner and for such forms of insurance as he prescribes,\ntheir experience under such forms and such other information as the\nsuperintendent may deem necessary or expedient for the administration of\nthis section and such experience and other information shall be compiled\nand analyzed as the superintendent prescribes.\n (h) (1) Each domestic insurer and each foreign or alien insurer doing\nbusiness in this state shall file with the superintendent its schedules\nof premium rates, rules and classification of risks for use in\nconnection with the issuance of its policies of group accident, group\nhealth or group accident and health insurance, and of its rates of\ncommissions, compensation or other fees or allowances to agents and\nbrokers pertaining to the solicitation or sale of such insurance and of\nsuch fees or allowances, exclusive of amounts payable to persons who are\nin the regular employ of the insurer, other than as agent or broker to\nany individuals, firms or corporations pertaining to such class of\nbusiness, whether transacted within or without the state. A group\naccident and health insurance policy providing disability and family\nleave benefits pursuant to article nine of the workers' compensation law\nshall be subject to the requirements of subsection (n) of this section.\n (2) An insurer may revise such schedules from time to time, and shall\nfile such revised schedules with the superintendent.\n (3) No insurer shall issue any policy of group accident, group health\nor group accident and health insurance the premium rate under which for\nthe first policy year is less than that determined by the schedules of\nsuch insurer as then on file with the superintendent; nor shall it pay\nto the agent or agents or to a broker or brokers for the solicitation or\nsale of such policy or for any other purpose related to such policy any\ncommission, compensation or other fees or allowances in excess of that\ndetermined on the basis of the schedules of such insurer as then on file\nwith the superintendent; nor shall such insurer pay for services\npertaining to the service or administration thereof to any individual,\nfirm or corporation any fees, commissions or allowances in excess of\nthat determined on the basis of the schedules of such insurer as then on\nfile with the superintendent or for such services not rendered in behalf\nof such insurer; provided, however, that nothing contained herein shall\napply to or affect the computation of dividends or experience rating\ncredits.\n (4) Nothing herein shall prohibit the state insurance fund from taking\ninto account peculiar hazards of individual risks in establishing higher\npremium rates to be charged for insurance providing for the payment of\ndisability and family leave benefits in accordance with article nine of\nthe workers' compensation law.\n (i) (1) Whenever the superintendent determines, after notice to all\ninsurers doing the business of group accident, group health or group\naccident and health insurance in this state and a hearing at which such\ninsurers may present pertinent statistics and other available data, that\nit is advisable in the administration of this section to adopt a\nschedule of minimum premium rates for any type of benefit provided under\npolicies of group accident, group health or group accident and health\ninsurance, the superintendent shall thereupon file in his office such a\nschedule which shall include a description of the benefit or benefits\nfor which minimum premium rates are being prescribed and of the minimum\npremium rates applicable thereto.\n (2) Such schedule may be revised by the superintendent from time to\ntime or withdrawn, after a similar notice and hearing.\n (3) The effective date of such schedule, or of any such revision or\nwithdrawal thereof, shall be specified by the superintendent. After the\neffective date of the first schedule no domestic insurer and no foreign\nor alien insurer doing business in this state shall issue, within or\nwithout this state, any policy of group accident, group health or group\naccident and health insurance providing any benefit to which the\nschedule of minimum premium rates then in effect applies, unless the\npremium for such benefit for the first policy year shall be at least\nequal to that determined on the basis of such schedule.\n (4) If an insurer desires to provide a benefit of the same general\ntype as, but not identical with, one described in said schedule, it\nshall before issuing any policy providing for such different benefit\nobtain the superintendent's approval of the premium proposed to be\ncharged therefor. The superintendent shall grant such approval if he is\nsatisfied that the proposed premium is not less than that which would\nhave to be charged consistent with the schedule of minimum premium rates\nthen in effect.\n (j) (1) Anything in this chapter to the contrary notwithstanding, any\npolicy of group accident, group health or group accident and health\ninsurance may provide for readjustment of the rate of premium based on\nthe experience thereunder at the end of the first year or of any\nsubsequent year of insurance thereunder, and such readjustment may be\nmade retroactive only for such policy year.\n (2) Any such rate readjustment shall be computed on a basis which is\nequitable to all group accident, group health or group accident and\nhealth insurance policies.\n (3) Any refund under any plan for readjustment of the rate of premium\nbased on the experience under group policies and any dividend paid under\nsuch policies may be used to reduce the employer's contribution to group\ninsurance for the employees of the employer, and the excess over such\ncontribution by the employer shall be applied by the employer for the\nsole benefit of the employees.\n (k) Whenever an insurer elects to terminate any policy as described in\nthis section, such insurer shall include in his notification of intent\nto terminate such policy reference to the policyholder's\nresponsibilities under section two hundred seventeen of the labor law.\nWhenever any policy as described in this section terminates as a result\nof a default in payment of premiums, the insurer shall notify the\npolicyholder that termination has occurred or will occur and shall\ninclude in his notification reference to the policyholder's\nresponsibilities under section two hundred seventeen of the labor law.\n (l) The superintendent shall promulgate rules and regulations\nconcerning the method, manner and time for a policyholder to provide\nwritten notice of termination to the certificate holders as required by\nsubdivision three of section two hundred seventeen of the labor law.\n (m) This section shall not apply to any contract issued by any article\nforty-three corporation except as provided in section four thousand\nthree hundred five of this chapter.\n (n)(1) On or before June first, two thousand seventeen, the\nsuperintendent of financial services by regulation, in consultation with\nthe chair of the workers' compensation board of this state, shall\ndetermine whether the family leave benefit coverage of a group accident\nand health insurance policy providing disability and family leave\nbenefits pursuant to article nine of the workers' compensation law,\nincluding policies issued by the state insurance fund, shall be\nexperience rated or community rated, which may include subjecting the\nfamily leave benefit coverage of the policy to a risk adjustment\nmechanism. Notwithstanding any law to the contrary, the superintendent\nshall establish the rates for any community rated family leave benefit\ncoverage and shall apply commonly accepted actuarial principles to\nestablish community rated family leave benefit coverage rates that are\nnot excessive, inadequate or unfairly discriminatory. On June first, two\nthousand seventeen and on September first of each year thereafter the\nsuperintendent shall publish all community rated family leave benefit\nrates for the policy period beginning on the following January first.\n (2) If the policy is subjected to a risk adjustment mechanism, the\nsuperintendent of financial services shall promulgate regulations\nnecessary for the implementation of this subsection in consultation with\nthe chair of the workers' compensation board of this state. Any such\nrisk adjustment mechanism shall be administered directly by the\nsuperintendent of financial services of this state, in consultation with\nthe chair of the workers' compensation board of this state, or by a\nthird party vendor selected by the superintendent of financial services\nin consultation with the chair of the workers' compensation board.\n (3) "Risk adjustment mechanism" as used in this subsection means the\nprocess used to equalize the per member per month claim amounts among\ninsurers in order to protect insurers from disproportionate adverse\nrisks.\n (o) (1) No contract or agreement between a health plan subject to this\narticle and a health care provider, other than a residential health care\nfacility as defined by section twenty-eight hundred one of the public\nhealth law, shall include a provision that:\n (A) contains a most-favored-nation provision; or\n (B) restricts the ability of a corporation, an entity that contracts\nwith a corporation for a provider network, or a health care provider to\ndisclose: (i) actual claims costs; or (ii) price or quality information\nrequired to be disclosed under federal law, including the allowed\namount, negotiated rates or discounts, or any other claim-related\nfinancial obligations, including, but not limited to, patient\ncost-sharing covered by the provider contract to any subscriber,\nenrollee, group, or other entity receiving health care services pursuant\nto the contract, or to any public compilation of reimbursement data such\nas the New York all payer database required by law or regulation,\nprovided that no disclosure shall include protected health information\nor other information covered by statutory or other privilege.\n (2) For purposes of this subsection, the term "health plan" shall\ninclude: (A) an insurer licensed pursuant to this chapter or a health\nmaintenance organization certified pursuant to article forty-four of the\npublic health law; and\n (B) a third-party administrator, affiliated with an insurer or health\nmaintenance organization, who administers a health benefit plan.\n