N.Y. Comp. Codes R. & Regs. tit. 11 § 360.7

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

Section 360.7 - Continuation of health insurance benefits

(a) Continuation of benefits coverage is to be provided pursuant to the requirements of sections 3221, 4304 and 4305 of the Insurance Law.

(b) Notice requirements applicable to continuation of benefits.

(1) An insurer shall provide in the policy, contract and certificate written notice of the right to continuation of benefits coverage provided by Insurance Law, sections 3221, 4304 and 4305 and shall notify the employer, policyholder or remitting agent, at the time of commencement of coverage, of the importance of the notification of the continuation benefit to each covered employee or member and the spouse of the employee or member.

(2) In the case of events described in sections 3221 (m)(4)(C), 4304 (k)(4)(C) and 4305 (e)(4)(C) of the Insurance Law, the employee or member or spouse of the employee or member (if any) shall be responsible for notifying the employer, policyholder or remitting agent, as applicable, of the occurrence of any such event within 60 days of such occurrence.

(3) In the case of determinations of disability made as described in sections 3221 (m)(4)(D), 4304 (k)(4)(D) and 4305 (e)(4)(D) of the Insurance Law, the employee or member or spouse of the employee or member (if any) shall be responsible for notifying the employer, policyholder or remitting agent, as applicable, within 60 days of such determination and also responsible for notifying the employer, policyholder or remitting agent, as applicable, within 30 days of any final determination that the disability in question no longer exists.

(4) Within 14 days of receipt of the notification described in paragraphs (2) and (3) of this subdivision, and within 14 days of any other event, condition or action which, as described in sections 3221 (m), 4304 (k) and 4305 (e) of the Insurance Law, cause termination of employment or membership in the class or classes eligible for coverage under the policy or contract, the employer, policyholder or remitting agent, as applicable, shall notify the employee or member or spouse of the employee or member (if any) of their rights under the continuation of benefits coverage described in subdivision (a) of this section.

(5) For purposes of the notification described in paragraph (4) of this subdivision, such notification to an individual who is the employee or a spouse of the employee or member shall be treated as notification to all other eligible dependents residing with such spouse at the time such notice is given.

(c) Election.

(1) Written request to elect continuation of coverage benefits must be given to the employer, policyholder or remitting agent, as applicable, by the employee or member or spouse of the employee or member (if any) within 60 days of the events described in Insurance Law, sections 3221(m), 4304(k) and 4305(e) which cause termination of coverage for the employee or member or eligible dependent of such employee or member or within 60 days of the date of the notice described in paragraph (b)(4) of this section, whichever period ends later.

(2) Such request for continuation of coverage for eligible dependents who are not the spouse of the employee or member may be made within such time period described in paragraph (1) of this subdivision by the employee or member or the spouse of the employee or member on such eligible dependents' behalf.

(d) Existing coverage.

(1) Employees and members and eligible dependents of such employees or members who began continuation of coverage benefits prior to January 1, 1993; and, whose coverage has not terminated prior to such date; and who shall be entitled, upon renewal, modification, alteration or amendment of the policy under which the continuation is provided, to continuation of benefits for the period as applicable pursuant to section 3221 (m) of the Insurance Law shall be entitled to continuation to the extent that the total period of continuation coverage shall not exceed the applicable time periods provided therein when calculated from the date the employee or member or other eligible dependent of the employee or member began such continuation of coverage.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 360.7