N.Y. Comp. Codes R. & Regs. tit. 11 § 52.18

Current through Register Vol. 46, No. 45, November 2, 2024

Section 52.18 - Prohibited provisions and coverages

(a) General rules.

(1) References to sources to determine factual situations, such as employee status, membership in a collective bargaining unit or a union, other benefits, salary, termination of employment or membership, are not incorporations by reference within the meaning of section 142(1) of the Insurance Law. Source documents or relevant excerpts therefrom referred to for such data as the plan of benefits expressed in a collective bargaining agreement or trust instrument shall accompany the policy filing.

(2) No policy or certificate shall be designated "basic" or "major medical" unless it provides at least the minimum benefits in section 52.5, 52.6 or 52.7 of this Part, respectively. Policies meeting the definition of section 52.8, 52.9 or 52.10 of this Part shall not be designated in any manner inconsistent with the applicable definition or which would encourage misrepresentation of the actual coverage provided.

(3) Where a policy is written that provides at least the coverages required for both basic hospital insurance under section 52.5 of this Part and basic medical insurance under section 52.6, the allowable deductible may be applied to the combined coverage.

(4) Where a policy is written that provides at least the coverages required for both basic hospital insurance under section 52.5 of this Part and basic medical insurance under section 52.6, the required anesthetic coverage may be provided as part of the miscellaneous hospital benefit instead of a separate anesthetic benefit, provided that the limit of the miscellaneous hospital benefit is sufficient to meet the combined minimum requirements of both the miscellaneous hospital benefit of basic hospital insurance and the anesthesia benefit of basic medical insurance.

(5) Policies which provide benefits as described in 42 U.S.C. section 300 gg - 91(c), except for policies defined in sections 52.11, 52.12, 52.13 and 52.14 of this Part and policies subject to the requirements of section 52.20 of this Part, may not exclude, limit or reduce coverage for a loss due to a preexisting condition for a period greater than 12 months following the effective date of an insured's coverage. Where a policy providing such benefits is delivered or issued for delivery to a group which includes persons aged 65 or older, such policy shall not contain any provision which excludes, limits or reduces coverage for a loss due to a preexisting condition for those aged 65 or older for a period greater than six months following the effective date of an insured's coverage. For purposes of this paragraph, a preexisting condition is one for which medical advice was given, treatment was recommended by or received from a physician, within six months before the effective date of an insured's coverage.

(6)

(i) Insurers issuing accident and health certificates which provide hospital or medical coverage on an expense incurred or indemnity basis to a person(s) eligible for Medicare shall provide to those applicants a Guide to Health Insurance for People with Medicare in the form developed jointly by the National Association of Insurance Commissioners and the Health Care Financing Administration and in a type size no smaller than 12-point type. Delivery of the guide shall be made whether or not such certificates are advertised, solicited or issued as Medicare supplement insurance as defined in this regulation. Except in the case of direct response insurers, delivery of the guide shall be made to the applicant at the time of application and written acknowledgment of receipt of the guide shall be obtained by the insurer. Direct response insurers shall deliver the guide to the applicant upon request but in no event later than at the time the certificate is delivered. If the guide has not been made available from the Health Care Financing Administration at the time that the insurer is required to deliver such guide, then the insurer shall provide the applicant with a notice that the guide is presently unavailable and that it will be delivered to the applicant at such time that it is available to the insurer.

(ii) For the purposes of this paragraph, form means the language, format, typesize, type proportional spacing, bold character, and line spacing.

(7)

(i) Any accident and health insurance certificate, other than a Medicare supplement certificate, a certificate issued pursuant to a contract under section 1876 of the Federal Social Security Act (42 U.S.C. section 1395 et seq.), disability income certificate, or a certificate evidencing accident and health insurance coverage under a group policy issued to a group described in subparagraph (A), (B), (C) or (D) of Insurance Law section 4235(c)(1), delivered or issued for delivery in this State to persons eligible for Medicare shall notify covered persons under the certificate that the certificate is not a Medicare supplement plan. The notice shall either be printed on or attached to the first page of the disclosure statement delivered to covered persons to comply with section 52.54 of this Part or to the first page of the certificate delivered to covered persons. The notice shall be in no less than 12-point type and shall contain the following language:

"THIS CERTIFICATE IS NOT A MEDICARE SUPPLEMENT PLAN. If you are eligible for Medicare, review the Guide to Health Insurance for People with Medicare available from the company."

(ii) Where applicable, applications provided to persons eligible for Medicare for the accident and health insurance coverages described in subparagraph (i) of this paragraph shall disclose, using the applicable statement prescribed in 42 U.S.C. section 1395 ss(d)(3)(D), the extent to which the certificate duplicates Medicare. The disclosure statement shall be provided as a part of, or together with, the application for the certificate.

(8)

(i) Unilateral modifications by an insurer to existing accident and health coverage shall be made in accordance with applicable laws upon at least 30 days' prior written notice to the policyholder.

(ii) An insurer may unilaterally modify the coverage for a policy of hospital, surgical or medical expense insurance only at the time of coverage renewal.

(iii) Where a policyholder is contractually required to provide prior written notice to terminate coverage, the notice referred to in subparagraph (i) of this paragraph must be provided to such policyholder no less than 14 days prior to the date by which the policyholder is required to provide notice to terminate coverage.

(9) At the time of an event described in 42 U.S.C. section 1395 ss(s)(3)(B) or (F) [FN*] because of which an individual loses coverage or benefits due to the termination of the policy or the individual ceases enrollment under the policy, the insurer of the policy from which termination or disenrollment occurs shall provide the individual with written notification of his or her rights and of the obligations of issuers of Medicare supplement insurance policies under Part 58 of this Title. If an individual loses coverage or benefits due to termination of the policy, such notification must be provided contemporaneously with the notification of termination. If an individual ceases enrollment under the policy, such notification must be provided within 10 working days of the insurer receiving notification of disenrollment.

(10) Insurers issuing policies and contracts subject to the provisions of sections 3221 (k)(6) or 4303 (s) of the Insurance Law shall use standards and guidelines no less favorable than those established and adopted by The American Society for Reproductive Medicine in relation to the following:

(i) the determination of infertility for the purposes of compliance with sections 3221 (k)(6)(C) and 4303 (s)(3) of the Insurance Law;

(ii) the identification of experimental procedures and treatments not covered for the diagnosis and treatment of infertility;

(iii) the identification of the required training, experience and other standards for health care providers for the provision of procedures and treatments for the diagnosis and treatment of infertility; and

(iv) the determination of appropriate medical candidates by the treating physician.

Said standards and guidelines are taken from The American Society for Reproductive Medicine's Practice Committee Opinions on The Definition of Experimental, The Definition of Infertility, The Guidelines for the Provision of Infertility Services and The Revised Minimum Standards for Invitro Fertilization, Gamete Intrafallopian Transfer and Related Procedures. These Practice Committee Opinions were approved by the Practice Committee of the American Society for Reproductive Medicine (formerly The American Fertility Society) on March 27, 1993 and approved by the Board of Directors of the American Society for Reproductive Medicine (formerly The American Fertility Society) on May 17, 1993. The Practice Committee Opinions may be obtained from The American Society for Reproductive Medicine formerly The American Fertility Society, 1209 Montgomery Highway, Birmingham, AL 35216-2809 and are available for public inspection and copying from the New York State Insurance Department at either 25 Beaver Street, New York, NY 10004 or One Commerce Plaza, Albany, NY 12257.

(11) Repealed

(12) Repealed

(13) An insurer issuing a policy subject to the provisions of Insurance Law sections 3217-g, 3221(l)(8), 4303(j) or 4306-f or Public Health Law section 4406-f that provides coverage for direct access to s creening and referral for maternal depression performed by a provider of obstetrical, gynecologic, or pediatric services of the mother's choice, shall provide coverage for the screening and referral for maternal depression under the mother's policy. However, if the infant is covered under a different policy than the mother and the screening and referral are performed by a provider of pediatric services, coverage for the screening and referral shall also be provided under the policy in which the infant is covered.

(b) Benefits.

(1) No policy shall predicate benefits on loss due to violent and external means. Accidental means shall be interpreted in New York in accordance with applicable New York case law.

(2) Specific dismemberment benefits shall not be in lieu of other benefits unless equal to or greater than the other benefits.

(3) Accidental death and dismemberment benefits shall be payable if the loss occurs within 90 days from the date of the accident, irrespective of total disability.

(4) Except as provided in paragraph (5) of this subdivision, upon termination of insurance, whether due to termination of employment, termination of eligibility or termination of the policy, an extension of benefits shall be provided during a period of total disability for hospital confinements commencing or surgery performed during the next 31 days for the injury, sickness or pregnancy causing the total disability.

(5) Where major medical insurance or insurance providing major medical type benefits is terminated by reason of termination of active employment, an extended benefit shall be provided during total disability, with respect to the sickness, injury or pregnancy which caused the disability, of at least 12 months subsequent to termination of insurance unless coverage is afforded for the total disability under another group plan.

(6)

(i) In addition to the requirements of paragraphs (4) and (5) of this subdivision, policies providing benefits for hospital and/or medical expenses may provide benefits for covered expenses incurred as a result of pregnancy, childbirth or related medical conditions if those expenses arise after termination of coverage, but as a result of pregnancies commencing while coverage is in force. If such benefits after termination of coverage are provided, it is not necessary to provide benefits for expenses incurred as a result of a sickness or injury commencing while coverage is in force if those expenses are incurred after termination of coverage, except as provided in paragraphs (4) and (5) of this subdivision.

(ii) If any policy providing coverage for pregnancies commencing while coverage is in force is revised to provide coverage for pregnancy for a different time period (e.g., coverage provided for the same period of time as for other medical conditions), the following shall apply:

(a) Any woman covered under the policy on the effective date of the revision who is then pregnant may not be deprived thereby of her right to coverage for that pregnancy to the extent of the benefits provided under the policy before it was revised, unless she qualifies under the revised policy for a greater benefit.

(b) Appropriate notice shall be given to the certificate holders that, in the event of termination of insurance, no benefits will be payable for expenses incurred after termination of coverage for a pregnancy commencing while coverage was in force unless at the time of termination the covered female was totally disabled.

(7) Disability benefits conditioned upon hospital confinement shall be considered as hospital, medical or surgical expense benefits for purposes of section 3221 (e) of the Insurance Law and any relevant regulations.

(8) Surgical fee schedules shall provide benefits for various surgical procedures which bear a rational relationship and reasonable relativity to each other based on the nature of the procedure. Schedules conforming to the relativities of the State of New York Certified Surgical Fee Schedule shall be deemed to meet requirements of this paragraph.

(9) Surgical schedules contained in the policy shall include a provision providing coverage for procedures not specifically listed in the schedules and not otherwise excluded by the policy and benefits therefor shall be consistent with the benefits for comparable procedures.

(10) Multiple surgical procedures performed during the same operative session and through the same incision shall be reimbursed in an amount not less than that stated in the schedule for the most expensive procedure then being performed. Multiple surgical procedures performed during the same operative session but through different incisions shall be reimbursed in an amount not less than that stated in the schedule for the most expensive procedure then being performed and with regard to the less expensive procedures in an amount at least equal to 50 percent of the scheduled amount for these procedures, unless a different amount is specifically set forth in the State of New York Certified Surgical Fee Schedule.

(11) In major medical insurance policies and policies providing major medical type benefits, the benefit period and the maximum amount payable during the benefit period shall be such that the maximum can reasonably be expected to be incurred during the benefit period, unless the policy maximum is designed to protect against catastrophic loss.

(12) In major medical insurance policies and policies providing major medical type benefits, if a benefit period commences with the first expense used to satisfy a deductible, and under the policy terms no further benefits become payable for the same cause after termination of such period, no benefit period shall end before the expiration of nine months after the deductible is satisfied, except when the benefit period is determined by a calendar date unrelated to the incidence of the first expense.

(13) Where disability income benefits are integrated with social security benefits, the policy shall provide that the amount of any disability benefits actually being paid to a disabled person shall not subsequently be reduced by changes in the level of social security benefits resulting from cost of living adjustment or changes in the Social Security Law which became effective after the first day for which disability benefits became payable.

(c) Renewal and cancellation.

(1) Notices of nonrenewal or termination shall provide for at least 30 days' prior notice except where otherwise specifically prescribed by statute. Any other conditions for nonrenewal or termination shall be fully set forth in the policy.

(2) No termination of coverage shall prejudice the right to a claim for benefits which arose prior to such termination.

(d) Nonduplication of coverage and coordination of benefits provisions.

(1) Coordination of benefits provisions in group contracts may apply to service type plans, prepaid group practice plans, group and blanket insurance, self-insured or noninsured plans, franchise plans, group salary continuance programs, State or Federal programs except Medicaid and mandatory no-fault automobile insurance benefits.

(2) Life, annuity or pension benefits under a plan of the same or a related employer may be offset against disability income benefits, subject to the following:

(i) early retirement benefits may be offset only if such early retirement is elected by the employee or does not reduce the amount of his accrued annuity or pension benefits then funded;

(ii) disability income benefits under a life insurance plan may be offset only if payment of such benefits does not reduce the amount of the employee's life insurance or if a employee may elect not to apply for such benefits even though disabled. The term related employer includes any individual, partnership or corporation under common control.

(3) No group or blanket policy of accident and health insurance may offset the payment of benefits thereunder by benefits provided pursuant to General Municipal Law section 205-c c

(e) Coverage of dependents.

(1) Except as required by law coverage of dependents is conditioned upon the employee or member being covered under the policy, however dependents' coverage may be continued following death of the employee or member, entry of the employee or member into military service, or similar circumstances.

(2) A family policy shall provide that adopted children and stepchildren dependent upon the insured be eligible for coverage on the same basis as natural children.

(3) A family policy covering a proposed adoptive parent on whom the child is dependent shall provide that such child be eligible for coverage on the same basis as a natural child during any waiting period prior to the finalization of the child's adoption.

(f) Conditions of eligibility. Conditions pertaining to employment under section 4235 (c) of the Insurance Law includes geographic situs of employment, earnings, method of compensation, hours, and occupational duties.

(g) Certificates and riders.

(1) Certificates must contain certifying language.

(2) Except for riders by which the insurer effectuates a request made in writing by the policyholder or exercises a specifically reserved right under the policy, all riders added to a policy after date of issue which reduce or eliminate coverage in the policy shall provide for signed acceptance by the policyholder.

[FN*] 42 United States Code 1395 ss(2007) published by Office of Law Revision Counsel, United States House of Representatives. It is available from the New York State Insurance Department, Office of General Counsel, 25 Beaver Street, New York, NY 10004.

(h) Telehealth.

(1) Telehealth has the meaning set forth in Insurance Law sections 3217-h and 4306-g and includes audio-only visits.

(2) For the purposes of Insurance Law sections 3217-h and 4306-g, an insurer may engage in reasonable fraud, waste and abuse detection efforts, including to prevent payments for services that do not warrant separate reimbursement.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.18

Amended New York State Register June 28, 2017 /Volume XXXIX, Issue 26, eff. 8/4/2017

Amended New York State Register October 31, 2018/Volume XL, Issue 44, eff. 10/31/2018

Amended New York State Register June 12, 2019/Volume XLI, Issue 24, eff. 8/11/2019

Amended New York State Register November 6, 2019/Volume XLI, Issue 45, eff. 1/1/2020

Amended New York State Register December 22, 2021/Volume XLIII, Issue 51, eff. 12/22/2021