N.Y. Comp. Codes R. & Regs. tit. 11 § 52.69

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

Section 52.69 - Rules relating to the content of health insurance identification cards

(a) Every issuer shall provide a health insurance identification card to the primary insured and to each dependent of the primary insured who is 18 years of age or older within 30 days of the effective date of the insured's or dependent's coverage, or if the insured or dependent is enrolled retroactively, within 30 days of the retroactive enrollment, under an accident and health insurance policy that provides coverage for comprehensive hospital, surgical and medical care, except coverage that is provided by this State to its employees or retirees or by governmental programs administered by the Commissioner of Health, including Medicaid, Children's Health Insurance Program, and Essential Plan. The health insurance identification card shall, at a minimum, contain the following information:

(1) the primary insured's name and identification number;

(2) each insured dependent's name and, if applicable, identification number, which shall appear either on the primary insured's identification card or on a separate card issued to the dependent;

(3) the full legal name of the issuer providing the coverage or the name under which the issuer is authorized to do business;

(4) a phrase that reads as follows: "fully insured coverage";

(5) the plan name;

(6) the coverage type, which shall be identified as point-of-service (POS), health maintenance organization (HMO), exclusive provider organization (EPO), preferred provider organization (PPO), or fee-for-service;

(7) the name of the issuer's health care provider network or networks for the plan, if applicable;

(8) the name of the plan's formulary, if applicable;

(9) the phone number or numbers at which the insured or health care provider may readily obtain the following:

(i) member services assistance;

(ii) confirmation of eligibility or verification of benefits; and

(iii) prior authorization for health care services, if applicable;

(10) the internet website address of the issuer;

(11) copayment or coinsurance information applicable to participating providers for the following services:

(i) primary care office visits;

(ii) specialist office visits;

(iii) urgent care;

(iv) emergency room visits; and

(v) prescription drugs for a 30-day supply at a retail pharmacy, if applicable;

(12) the annual or plan year deductible amount for participating providers, if applicable; and

(13) the plan's annual maximum out-of-pocket amount.

(b) An issuer shall post conspicuously on its website the name of the issuer's health care provider network or networks for the plan and the name of the plan's formulary, as applicable. The names posted on the issuer's website shall match the names listed on the health insurance identification card.

(c) When any information required to be on the card is changed, each issuer shall provide the primary insured and each dependent of the primary insured who is 18 years of age or older and covered under the accident and health insurance policy with a new health insurance identification card upon renewal of the policy. However, if the information in paragraph (11) of subdivision (a) of this section is the only information that is changed, an issuer may provide a sticker containing the new information that is to be affixed to the card to the primary insured and each dependent of the primary insured who is 18 years of age or older and covered under the accident and health insurance policy upon renewal of the policy.

(d) A health insurance identification card shall be mailed to the primary insured and to each dependent of the primary insured who is 18 years of age or older. If a dependent who is 18 years of age or older resides with the primary insured, the issuer may include the dependent's card in the mailing to the primary insured with the primary insured's card. A health insurance identification card may be provided electronically, and not by mail, if the insured or dependent 18 years of age or older consents to electronic delivery for his or her card.

(e) Every issuer, when acting as an administrator on behalf of a group that provides coverage for comprehensive hospital, surgical, and medical care under a self-funded plan, shall, if the issuer's name appears on any health insurance identification card, include a phrase that reads as follows: "self-funded coverage."

(f) For purposes of this section, "issuer" means an insurer licensed to write accident and health insurance in this State, a corporation organized pursuant to Insurance Law article 43, a municipal cooperative health benefit plan certified pursuant to Insurance Law article 47, a health maintenance organization certified pursuant to Public Health Law article 44, and a student health plan certified pursuant to Insurance Law section 1124.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 52.69

Adopted New York State Register December 23, 2020/Volume XLII, Issue 51, eff. 4/22/2021

Amended New York State Register June 15, 2022/Volume XLIV, Issue 24, eff. 7/15/2022