N.Y. Comp. Codes R. & Regs. tit. 11 § 361.2

Current through Register Vol. 46, No. 50, December 11, 2024

Section 361.2 - Definitions

As used in this Part, the following words and phrases are defined as follows:

(a) Article 43 corporation means a corporation organized under article 43 of the Insurance Law.

(b) Average demographic factor means the weighted average demographic index of each carrier. The index for a particular carrier reflects the expected relative costs for that carrier, based only upon the demographic factors of the persons it covers, compared to the expected average costs of all carriers, based only upon the demographic factors of all persons covered by all carriers.

(c) Carrier 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.

(d) Carrier participating in a pool means, with respect to a pool for a particular area, a carrier which has in force one or more pooled individual health insurance policies covering individuals residing in the pool area, or which has in force one or more pooled small group insurance policies covering small groups located in the pool area. With respect to small groups, all members of the group shall be considered to be located in the same pool area as the group itself, regardless of the location of the residences of the members.

(e) Demographic pooling fund means, with respect to a particular demographic pool, a fund which is equal to paragraph (1) plus paragraph (2), minus paragraph (3), minus paragraph (4) of this subdivision:

(1) amounts paid to the fund by carriers participating in the pool, as stated in section 361.3(e) and (h) of this Part;

(2) investment income on the fund;

(3) amounts paid from the fund to carriers participating in the pool, as stated in section 361.3(f) and (h) of this Part; and

(4) amounts paid from the fund to the administrator for administration of the fund, as stated in section 361.6(a)(3) and (6) of this Part.

(f) Earned premiums (or premiums earned) means premium income to a carrier collected during a particular period, adjusted for overdue premiums and premiums collected for coverage which extends beyond the end of the period. Instructions relating to earned premium are found in the following:

(1) for an article 43 corporation, in the current New York Instructions To Hospital, Medical, and Dental Service or Indemnity Corporations For Completing Annual Statement Blank;

(2) for a health maintenance organization, in the current General Information and Instructions For Filing The New York Data Requirements For Health Maintenance Organizations; and

(3) for a commercial insurance carrier or a fraternal benefit society, in the current NAIC Annual Statement Instructions--Life, Accident, and Health.

(g) Family unit means the following:

(1) for an article 43 corporation--contractholder or certificateholder;

(2) for a health maintenance organization--subscriber;

(3) for individual health insurance of a commercial insurance company-- policyholder; and

(4) for small group health insurance other than that of an article 43 corporation or a health maintenance organization--certificateholder.

(h) Health maintenance organization means an organization (or line of business of an article 43 corporation) which has received a certificate of authority from the Commissioner of Health pursuant to article 44 of the Public Health Law, or, an article 43 corporation which is qualified within the meaning of section 1310(c) of title XIII of the Public Health Service Act.

(i) Incurred claims (or claims incurred) means all policy and contract claims settled, or medical and hospital expenses paid during a particular period, adjusted for reported but unpaid claims and expenses, and for unreported claims or medical and hospital expenses incurred during that period. Instructions relating to incurred claims are found in the following:

(1) for an article 43 corporation, New York Instructions To Hospital, Medical, and Dental Service or Indemnity Corporations For Completing Annual Statement Blank;

(2) for a health maintenance organization, General Information and Instructions For Filing The New York Data Requirements For Health Maintenance Organizations; and

(3) for a commercial insurance carrier or a fraternal benefit society, NAIC Annual Statement Instructions--Life, Accident, and Health.

(j) Individual health insurance policy means an insurance policy written by a carrier under the provisions of sections 3216, 4304, 4321, 4322 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.

(k) Medicare supplement insurance policy means an insurance policy or contract defined in section 52.11 of this Title, and similar policies or contracts issued prior to May 1, 1992 which supplement Medicare benefits as well as Medicare select policies and certificates as defined in section 52.14 of this Title.

(l) Pool area means one of the following regions:

(1) Albany area--the counties of Albany, Rensselaer, Washington, Warren, Essex, Clinton, Saratoga, Schenectady, Schoharie, Montgomery and Fulton.

(2) Buffalo area--the counties of Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming.

(3) Mid-Hudson area--the counties of Putnam, Dutchess, Columbia, Greene, Ulster, Orange, Sullivan and Delaware.

(4) New York City area--the counties of Suffolk, Nassau, Kings, Queens, Richmond, New York, Bronx, Rockland and Westchester.

(5) Rochester area--the counties of Monroe, Livingston, Ontario, Wayne, Yates and Seneca.

(6) Syracuse area--the counties of Broome, Cayuga, Chemung, Cortland, Onondaga, Schuyler, Steuben, Tioga, and Tompkins.

(7) Utica/Watertown area--the counties of Chenango, Franklin, Hamilton, Herkimer, Jefferson, Lewis, Madison, Oneida, Oswego, Otsego, and St. Lawrence.

(m) Pooled insurance (or pooled insurance policy) means, for a particular period, all individual health insurance policies and all small group health insurance policies in force during that period, except for the following:

(1) Individual or group policies issued pursuant to a statutory or contractual right of conversion, other than those which could have been obtained directly on an open enrollment basis, without reference to the statutory or contractual right of conversion.

(2) Policies or contracts issued to local social service districts, covering Medicaid recipients.

(3) Medicare risk contracts, cost contracts, and health care prepayment plans, as defined in sections 1876 and 1833 of the Federal Social Security Act and Medicare + Choice contracts as defined in section 1851 of the Federal Social Security Act.

(4) Individual health insurance policies that are guaranteed renewable and noncancellable individual health insurance policies, as those terms are defined in sections 52.17(a)(5) or (6), and 58.1(b)(1) of this Title, which guaranteed renewable and/or noncancellable policies were delivered or issued for delivery prior to February 1, 1993, provided no such policies of this form were issued by the insurer on or after February 1, 1993. All such policies of a form issued on or after February 1, 1993 are included under pooled insurance, regardless of their date of issue or delivery.

(5) Policies granted an exemption from community rating, in accordance with section 360.4(f)(2) of this Title.

(n) Regional demographic factor for a particular pool means the combined average demographic factor for that pool of all carriers participating in the pool, using the same methodology defined in section 361.3(c) of this Part for a single carrier.

(o) Regional specified medical condition index means the combined average specified medical condition index for the specified medical condition pool for all carriers participating in the pool, using the same methodology as defined in section 361.4(f) of this Part for a single carrier.

(p) Small group health insurance policy means a group remittance policy written by a carrier 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 section 360.2(a) of this Title. In determining the size of a small group, reference should be made to section 360.4(i) and (j) of this Title. 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.

(q) Specified medical condition index means the index for a particular carrier. The index for a particular carrier reflects the cost of incurred claims for specified medical conditions relative to the contributions to the specified medical condition pooling fund as required by section 361.4 of this Part. The methodology to determine this index is defined in section 361.4(f) of this Part.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 361.2