NEW YORK STATE
FIRST AMENDMENT TO REGULATION NO. 171
(11 NYCRR 362)
THE HEALTHY NEW YORK PROGRAM
THE DIRECT PAYMENT STOP LOSS RELIEF PROGRAM
I, GREGORY V. SERIO, Superintendent of Insurance, pursuant to the authority granted by sections 201, 301, 1109, 3201, 3216, 3217, 3221, 4235, 4303, 4304, 4305, 4318, 4326 and 4327 of the Insurance Law of the State of New York, do hereby promulgate the following First Amendment to Part 362 of Title 11 of the Official Compilation of Codes, Rules and Regulations (Regulation No. 171), to take effect upon publication in the State Register to read as follows:
(NEW MATTER IS UNDERSCORED. MATTER IN BRACKETS IS DELETED.)
Section 362-2.3 is hereby amended to read as follows:
§ 362-2.3 Enrollment.
(a) Applications for qualifying health insurance contracts shall be made directly to health maintenance organizations and participating insurers.
(b) Health maintenance organizations and participating insurers shall provide all necessary information and enrollment forms when requested by applicants.
(c) Health maintenance organizations and participating insurers shall collect the initial eligibility certifications required by section 4326(i) of the Insurance Law and necessary supporting documentation and shall be responsible for examination of such certifications and supporting documentation for verification that applicants meet applicable eligibility requirements. Health maintenance organizations and participating insurers shall accept any standardized application form that may be prescribed by the superintendent.
(d) Unless the superintendent suspends enrollment in the Healthy New York program pursuant to section 4327(k) of the Insurance Law or approves a request to suspend qualifying individual enrollment pursuant to subsection (h) of this section, all applicants meeting eligibility criteria shall be accepted and coverage must be issued on the first day of the month next succeeding the date a complete application has been submitted for all applications submitted on or prior to the 20th day of such month. For applications submitted after the 20th day of a month, coverage shall be issued no later than the first of the month next following. Dependent children up to at least age 19 and full-time students up to at least age 23 shall be considered eligible dependents under qualifying health insurance contracts.
(e) Health maintenance organizations and participating insurers shall provide applicants which have failed to demonstrate eligibility with a written notice of denial which clearly sets forth the basis for the denial.
(f) Health maintenance organizations and participating insurers must submit monthly enrollment reports which detail total enrollment in the Healthy New York program in the format specified by the superintendent. Such reports shall identify the health maintenance organizations or participating insurers total enrollment in the Healthy New York program as of the first day of the following month and must be submitted to the superintendent no later than the fifteenth day of the following month.
(g) In the event that the enrollment in the small employer or individual Healthy New York program is suspended pursuant to section 4327(k) of the Insurance Law, participating insurers and health maintenance organizations shall:
(1) notify applicants that enrollment has been suspended; and
(2) maintain a waiting list to be filled in the order of receipt in the event that enrollment is reactivated.
(h) Commencing June 1, 2001, if monthly enrollment reports indicate that a given health maintenance organization or participating insurers total enrollment under qualifying individual health insurance contracts exceeds 50% of that health maintenance organizations or participating insurers total enrollment in the Healthy New York program, the health maintenance organization or participating insurer may submit a request to the superintendent to suspend the issuance of its qualifying individual health insurance contracts. If approved by the superintendent, the suspension shall take effect on the date specified by superintendent and shall be for the period specified by the superintendent. A participating insurer or health maintenance organization that has received approval to issue such a suspension shall:
(1) notify applicants that enrollment has been suspended;
(2) maintain a waiting list to be filled in the order of receipt in the event that enrollment is reactivated; and
(3) on a quarterly basis, submit reports detailing the claims experience of the Healthy New York product. Such reports shall segregate the claims experience of qualifying individuals from the claims experience of qualifying small employers and individual proprietors.
(i) An enrollment suspension pursuant to section 4327(k) of the Insurance Law or pursuant to subsection (h) of this section shall not preclude the addition of dependents or new employees to existing qualifying health insurance contracts. Additionally, an enrollment suspension shall not prevent the enrollment of persons exercising a statutory right of conversion to a qualifying individual insurance contract.
(j) Nothing herein is intended to preclude, diminish or in any way impair the involvement of chambers of commerce, trade associations and other similar entities in the Healthy New York Program in any manner otherwise permitted by law or regulation.
Section 362-4.3 is hereby amended to read as follows:
§ 362-4.3 Verification of net household income.
(a) To qualify for coverage under the Healthy New York program, individual proprietors and working uninsured individuals must satisfy the household income criteria set forth in Sections 4326(c)(1)(A)(ii) and 4326(c)(3)(A)(iii) of the Insurance Law. For the purpose of determining household income eligibility, household members shall include the applicant, the applicants legal spouse if residing in the household and any children eligible for coverage under the policy. Income received by the applicant[, their] and the applicants legal spouse [and any other family members] residing in the household shall be counted.
(b) Income shall include, but shall not be limited to, the following:
(1) monetary compensation for services including wages,
salary, commissions, overtime compensation, fees or tips;
(2) net income from farm and non-farm self-employment;
(3) Social Security payments or benefits;
(4) dividends, interest on savings or bonds, regular income from estates or trusts, or net rental income;
(5) unemployment compensation;
(6) government, civilian employee or military retirement or pension or veterans payments;
(7) private pension or annuity;
(8) alimony or child support payments received;
(9) regular contributions from persons not living in the household;
(10) net royalties; and
(11) such other income as determined by the superintendent.
(c) Income shall not include public assistance; SSI; foster care payments; capital gains; any assets drawn down as withdrawals from a bank; receipts from the sale of property; or payments for compensation for injury. Also excluded are non-cash benefits, such as employee fringe benefits, food or housing received in lieu of wages, and receipts from federal non-cash benefit programs.
(d) Health maintenance organizations and participating insurers shall collect such documentation as is necessary and sufficient to initially, and annually thereafter, verify that the household income requirements of the Healthy New York program have been satisfied. Such documentation may include, but not be limited to one or more of the following:
(1) annual income tax returns and, if not prohibited by federal law for purposes of income verification, the social security account number;
(2) paycheck stubs;
(3) written documentation of income from all employers; or other documentation of income (earned or unearned) as determined by the superintendent to be acceptable, provided however, such documentation shall set forth the source of such income.
I, Gregory V. Serio, Superintendent of Insurance, do hereby certify that the foregoing is the First Amendment to 11 NYCRR 362 (Regulation No. 171), promulgated by me on January 21, 2004 pursuant to the authority granted by Sections 201, 301, 1109, 3201, 3216, 3217, 3221, 4235, 4303, 4304, 4305, 4318, 4326 and 4327 of the Insurance Law, to take effect upon publication in the State Register.
Pursuant to the provisions of the State Administrative Procedure Act, prior notice of the proposed amendment was published in the State Register on November 19, 2003. No other publication or prior notice is required by statute.
Superintendent of Insurance
January 21, 2004