N.Y. Comp. Codes R. & Regs. tit. 11 § 360.2

Current through Register Vol. 46, No. 43, October 23, 2024

Section 360.2 - Definitions

(a) Association group means a group defined in section 4235 (c)(1)(B) (D) (H) (K) (L) and (M) of the Insurance Law, including but not limited to an association or trust of employers, if the group includes one or more member employers or other member groups which have 50 or fewer employees or members exclusive of spouses and dependents. A group containing individual members of an association will be considered an association group having member groups of 50 or fewer members.

(b) Community rated means a rating methodology in which the premium for all persons covered by a policy or contract form is the same based on the experience of the entire pool of risks covered by that policy or contract form without regard to age, sex, health status or occupation. Refunds, rebates, credits or dividends based on such factors are also prohibited.

(c) Individual health insurance policy means an insurance policy written by an insurer under the provisions of sections 3216, 4304 and 4501 (o) of the Insurance Law, issued directly to an individual (not on a group or group remittance basis), except for policies covering only: long term care benefits, nursing home benefits, home care benefits, dental or vision care services, hospital or surgical indemnity benefits with specific dollar amounts unless the dollar amounts exceed the amounts required to meet the definitions of basic hospital and basic medical insurance in sections 52.5 and 52.6 of this Title, accident only indemnity benefits, accidental death and dismemberment benefits, prescription drug benefits, disability income benefits or specified disease benefits.

(d) Insurer means any commercial insurance company, any fraternal benefit society, or any corporation licensed under article 43 of the Insurance Law or article 44 of the Public Health Law, other than a social health maintenance organization, unless otherwise specified in the regulation.

(e) Open enrollment means that any individual, and dependents of such individual, and any small group, including all eligible employees or group members and dependents of employees or members, applying for individual or small group health insurance coverage, including Medicare supplement coverage, must be accepted at all times throughout the year for any hospital and/or medical coverage offered by the insurer to individuals or small groups in this state, and once accepted for coverage, an individual or small group cannot be terminated by the insurer due to claims experience.

(f) Small group health insurance policy means a group remittance policy written by an insurer pursuant to section 4304 of the Insurance Law and a group health insurance policy covering from two to 50 employees or members, exclusive of dependents and spouses, and policies issued to or through association groups as defined in subdivision (a) of this section. In determining the size of a small group reference should be made to section 360.4(i) and (j) of this Part. Insurers may choose to classify individual proprietors within the small group category provided that any such classification is applied consistently to all individual proprietors. A small group health insurance policy does not include a policy covering only: long term care benefits, nursing home benefits, home care benefits, dental or vision care services, hospital or surgical indemnity benefits with specific dollar amounts unless the dollar amounts exceed the amounts required to meet the definitions of basic hospital and basic medical insurance in sections 52.5 and 52.6 of this Title, accident only indemnity benefits, accidental death and dismemberment benefits, prescription drug benefits, disability income benefits or specified disease benefits.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 360.2