NY State Senate Bill 2009-S3062

Archive: Last Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 06, 2010	referred to insurance
Mar 10, 2009	referred to insurance

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2009-S3062 (ACTIVE) - Details

See Assembly Version of this Bill:: A4688
Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§3231, 4308, 3216, 3221, 4303 & 3224-a, Ins L; amd §4406, Pub Health L

2009-S3062 (ACTIVE) - Summary

Enacts the health insurance premium integrity act; amends procedures for determination of loss ratio; amends provisions relating to payment of dividends and credits; relates to coverage of services of participating providers

2009-S3062 (ACTIVE) - Sponsor Memo

                                 BILL NUMBER:  S3062

 TITLE OF BILL :
An act to amend the insurance law, in relation to premium rates for
health insurance; to amend the insurance law and the public health
law, in relation to coverage of services of participating providers;
and to amend the insurance law, in relation to the fair and equitable
settlement of claims for health care and payments for health services


 PURPOSE :
The purpose of this legislation is to strengthen the tile and use
process for health insurance, by establishing clear definitions and
standards for calculating medical loss ratios. The bill also
reinstates prior approval for insurers who misrepresent their medical
loss ratios in two consecutive years. The legislation further
clarifies standards for when in-network/out-of-network rates may be
charged. Finally, the bill reduces the prompt pay timeframe for
electronic claims from 45 days to 21 days.

 SUMMARY OF PROVISIONS :
Section 1 of the bill captions it the "Health Insurance Premium
Integrity Act."

Section 2 of the bill amends subsection (e) of Section 3231 of the
Insurance Law to provide a definition of the terms "policy form,"

"loss ratio," "direct claims incurred," "direct claims earned" and
"small group." It also sets the minimum loss ratio for small group
policies at eighty percent and provides that where the application of
the minimum loss ratio test results in a premium credit or a dividend,
the credit or dividend applies to all policies in force at the
applicable time, whether or not the policyholder remains covered by
the health plan when the dividend or credit is issued. This section
further provides the method to calculate direct claims incurred to be
used in determining the minimum loss ratio and gives the
Superintendent of Insurance the authority to suspend an insurer's
ability to use the alternative premium rate adjustment process if it
is determined that the insurer materially misrepresented the minimum
loss ratio in its tilings on two consecutive occasions and filed to
provide a required dividend within three years.

Section 3 of the bill amends Section 430R of the Insurance Law to
define the terms "contract form," '"loss ratio," "direct claims
incurred," "direct premium earned" and "small group."

Section 4 of the bill increases the minimum loss ratio for small group
and small group remittance contracts from seventy-five percent to
eighty percent and indicates that the actuarial certification that
accompanies premium rate adjustment filings under the alternative
method shall be subscribed to under penalty of perjury.

Sections 5 and 8 of the bill change the minimum loss ratio for small
group and small group remittance contracts to eighty percent and
provides that where a premium credit or dividend is due, it shall be
issued to each contract that was in effect during the applicable time,
whether or not the contract holder remains covered by the health plan
at the time it is actually issued The sections further provides the
method to calculate direct claims incurred to be used in determining
the minimum loss ratio, and changes the reporting date from May 1 to
August 1.

Section 6 of the bill gives the Superintendent of Insurance the
authority to suspend an Article 43 corporation or an HMO's ability to
use the alternative premium rate adjustment process if it is
determined that the insurer materially misrepresented the minimum loss

ratio in its filings on two consecutive occasions and filed to provide
a required dividend within three years.

Section 7 of the bill makes technical changes to the law.

Sections 9 through 12 of the bill amends sections 3216,3221, and 4303
of the insurance law and section 4406 of the public health law to
prohibit health insurers from charging a patient out-of-network rates
for hospital services in an in-network hospital even though the
physician performing the service may be out-of-network. These sections
further prohibit health insurers from charging a patient
out-of-network rates for services performed by an in-network
physician, even though the hospital where the services are performed
may be out-of-network.

Section 13 of the bill amends section 3224-a of the insurance law to
reduce the required time that an insurer must pay claims to health
care providers when the claim is submitted electronically, from 45
days to 21 days.

Section 14 of the bill amends section 3224-a of the insurance law to
require an insurer to provide written notification within 14 days
after an electronic claim is submitted if such claim will be disputed.

 JUSTIFICATION :
Prior to 1996 (1994 for commercial insurers), all premium rate
adjustments of individual and small group health insurance policies
and contracts required the prior approval of the Superintendent of
Insurance.  For HMOs and for Article 43 corporations, a public hearing
was also required as part of the rate adjustment process.  The change
to a "file and use" system was made to address the legitimate concerns
that the prior approval process was overly subjective or political
administratively burdensome and costly and, as a result, did not allow
appropriate rate changes. Adoption of the "file and use" process was
not made without appropriate standards and marketplace controls All
new products continued to be subject to an initial prior approval and,
for existing products, an actuarially based minimum loss ratio test
was required which permitted a rate increase only when a product
dedicated a certain percentage of the premium to the payment of claims
for health care services. Moreover, a required dividend or credit for
failing to meet the test was put in place to ensure that the adjusted
rate implemented through this alternative process was justified and
equitable.

This proposal seeks to address the concerns many have raised that the
current "file and use" system does not contain enough safeguards
against inappropriate or excessive increases. There are allegations
that the minimum loss ratio test is ambiguous and subject to
manipulation and, as such, allows insurers, Article 43 corporations
and HMOs to implement excessive rates. Some parties suggest a return
to the prior approval process.

This bill takes a measured approach to addressing those concerns by
expanding the safeguards built into the existing process rather than
taking a step backward to the artificially suppressed price control
process of "prior approval".  The bill responds to the concern that
loss ratios are capable of manipulation by providing a definition of
medical loss ratio and a means of calculating incurred claims. It
gives the Superintendent of Insurance the authority to suspend a
health plan's ability to use the "file and use" process where the
health plan shows a pattern of intentionally manipulating data to
obtain a favorable result.  Specifically, the bill would reinstate
prior approval for insurers who "materially misrepresent" their
medical loss ratios in two consecutive years, and would be in effect
for up to three years This suspension is in addition to other punitive

remedies already available to the Superintendent under the Insurance
Law.

We all recognize that there are good players and bad players in the
health insurance market. The intent of this legislation is to penalize
the bad actors, those who deliberately play games a11d misrepresent
their loss ratios to the insurance department. Those who play by the
rules should be permitted to continue to enjoy the benefits of "file
and use.

Further, the bill increases the minimum medical loss ratio from 75% to
80%, for the small group market, meaning that at least 80 cents of
every premium dollar must be used to pay for health care services.
This higher ratio is an important way of ensuring that a greater
amount of the premium dollar is returned in health care benefits as
opposed to administrative overhead costs or profits for this price
sensitive market. The bill also establishes clear definitions and
standards for calculating medical loss ratios, and provides a specific
method for calculating "direct claims incurred." This is designed to
eliminate the "gaming" used by certain health plans, whereby they
deliberately miscalculate their minimum loss ratios. The current test
for meeting minimum medical loss ratios is ambiguous and subject to
manipulation. allowing for insurers to implement excessive rates. The
bill further strengthens certification requirements. by requiring
insurers to affirm. under penalty of perjury. that their rate filing
was prepared in accordance with generally accepted actuarial
principles.

The legislation also prohibits health insurers from charging a patient
out-of-network rates for hospital services in an in-network hospital,
even though the physician performing the service may be
out-of-network. In other words. as long as a patient is being treated
in an in-network hospital, he must be charged in-network rates for the
hospital services he receives. Similarly, the legislation also
prohibits health insurers from charging a patient out-of-network rates
for services performed by an in-network physician, even though the
hospital where the services are performed may be out-of-network.  In
other words. if the physician is in-network but the hospital is
out-of-network, the patient must be charged in-network rates

The legislation also reduces the required time that an insurer must
pay claims to health care providers when the claim is submitted
electronically, from 45 days to 21 days. Claims that are submitted in
written form would remain unchanged, at 45 days. This will ensure that
payments to health care providers are made expeditiously. Also, by
reducing the time frame for electronic claims only, we are
subsequently providing an incentive for providers to submit claims
electronically.

 LEGISLATIVE HISTORY :
S.8354-B of 2008

 FISCAL IMPLICATIONS :
None.

 EFFECTIVE DATE :
Immediately.

2009-S3062 (ACTIVE) - Bill Text download pdf

                            
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  3062

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                             March 10, 2009
                               ___________

Introduced  by  Sens.  SEWARD, VOLKER -- read twice and ordered printed,
  and when printed to be committed to the Committee on Insurance

AN ACT to amend the insurance law, in  relation  to  premium  rates  for
  health  insurance;  to  amend  the insurance law and the public health
  law, in relation to coverage of services of  participating  providers;
  and  to amend the insurance law, in relation to the fair and equitable
  settlement of claims for health care and payments for health services

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  This  act  shall be known and may be cited as the "health
insurance premium integrity act".
  S 2. Subsection (e) of section 3231 of the insurance law, as added  by
chapter 501 of the laws of 1992, is amended to read as follows:
  (e)  (1)  DEFINITIONS.  FOR  PURPOSES OF THIS SUBSECTION:  (A) "POLICY
FORM" SHALL MEAN A POLICY OR POLICIES AND ASSOCIATED RIDERS WHOSE  EXPE-
RIENCE  HAS  BEEN POOLED IN ORDER TO DETERMINE RATES FOR EACH POLICY AND
EACH RIDER;
  (B) "LOSS RATIO" SHALL MEAN THE RATIO OF DIRECT  CLAIMS  INCURRED  FOR
THE  REPORTING  CALENDAR  YEAR  TO  DIRECT  PREMIUMS EARNED FOR THE SAME
REPORTING CALENDAR YEAR, EXPRESSED AS A PERCENTAGE;
  (C) "DIRECT CLAIMS INCURRED" SHALL MEAN CLAIMS PAID DURING THE REPORT-
ING CALENDAR YEAR PLUS THE UNPAID CLAIMS  RESERVE  AT  THE  END  OF  THE
REPORTING  CALENDAR YEAR AND CALCULATED CONSISTENT WITH SUBPARAGRAPH (C)
OF PARAGRAPH THREE OF THIS SUBSECTION;
  (D) "DIRECT PREMIUMS EARNED" SHALL MEAN PREMIUMS  WRITTEN  DURING  THE
REPORTING  CALENDAR  YEAR PLUS THE UNEARNED PREMIUMS AT THE BEGINNING OF
THE YEAR LESS THE UNEARNED PREMIUMS AT THE END OF THE YEAR, EXCLUSIVE OF
REINSURANCE ASSUMED OR CEDED; AND
  (E) "SMALL GROUP" SHALL MEAN A GROUP POLICY THAT  IS  SUBJECT  TO  THE
REQUIREMENTS OF THIS SECTION.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD07620-01-9

S. 3062                             2

  (2)  An  insurer desiring to increase or decrease premiums after April
first, nineteen hundred ninety-three for any policy form subject to this
section shall submit a rate filing or application to the superintendent.
The superintendent shall determine whether  the  filing  or  application
shall  become effective as filed, shall become effective as modified, or
shall be disapproved.
  [(2)] (3) (A) Beginning October first, nineteen  hundred  ninety-four,
as  an alternate procedure to the requirements of paragraph [one] TWO of
this subsection, an insurer desiring to increase  or  decrease  premiums
for  any  policy  form subject to this section may instead submit a rate
filing or application to the  superintendent  and  such  application  or
filing shall be deemed approved, provided that (i) the anticipated mini-
mum  loss  ratio [for a policy form] shall not be less than seventy-five
percent of the premium FOR AN INDIVIDUAL HEALTH INSURANCE POLICY AND NOT
LESS THAN EIGHTY PERCENT OF THE PREMIUM FOR A SMALL GROUP HEALTH  INSUR-
ANCE  POLICY,  and  (ii)  the insurer submits, as part of such filing, a
certification by a member of the American Academy of Actuaries or  other
individual  acceptable  to  the  superintendent  that  the insurer is in
compliance with the  provisions  of  this  paragraph,  based  upon  that
person's  examination, including a review of the appropriate records and
of the actuarial assumptions and methods used by the insurer  in  estab-
lishing  premium  rates  for policy forms subject to this section.  SUCH
CERTIFICATION SHALL AFFIRM THAT THE RATE FILING OR APPLICATION SUBMITTED
TO THE SUPERINTENDENT  PURSUANT  TO  THIS  SUBSECTION  WAS  PREPARED  IN
ACCORDANCE   WITH  GENERALLY  ACCEPTED  ACTUARIAL  PRINCIPLES  AND  THIS
SECTION.   THE INSURER SHALL, AT  THE  REQUEST  OF  THE  SUPERINTENDENT,
PROVIDE  ADDITIONAL  UNDERLYING  ACTUARIAL  DOCUMENTATION TO SUPPORT THE
RATE FILING OR APPLICATION. PROVIDED,  HOWEVER,  THE  REQUEST  FOR  SUCH
INFORMATION  SHALL  NOT  PRECLUDE  THE  NEW PREMIUM RATE FROM GOING INTO
EFFECT.
  (B) Each calendar year, an insurer shall return, in the form of aggre-
gate benefits for each policy  form  filed  pursuant  to  the  alternate
procedure  set  forth in this paragraph at least seventy-five percent of
the aggregate premiums collected for  the  INDIVIDUAL  HEALTH  INSURANCE
policy  form  during that calendar year, OR EIGHTY PERCENT OF THE AGGRE-
GATE PREMIUMS COLLECTED FOR A SMALL GROUP HEALTH INSURANCE  POLICY  FORM
DURING  THAT  CALENDAR YEAR.  IF AN INSURER HAS POOLED THE EXPERIENCE OF
POLICIES AND/OR RIDERS TO DETERMINE THE  PREMIUM  RATES,  IN  ACCORDANCE
WITH  APPLICABLE  LAW,  THE  INSURER  SHALL CALCULATE THE LOSS RATIOS IN
ACCORDANCE WITH THE MANNER IN WHICH IT ESTABLISHED  THE  PREMIUM  RATES.
Insurers shall annually report, no later than [May] AUGUST first of each
year, the loss ratio calculated pursuant to this paragraph for each such
policy  form for the previous calendar year. In each case where the loss
ratio for a policy form fails to comply with  the  seventy-five  percent
loss ratio requirement FOR AN INDIVIDUAL HEALTH INSURANCE POLICY, OR THE
EIGHTY  PERCENT  MINIMUM LOSS RATIO REQUIREMENT FOR A SMALL GROUP HEALTH
INSURANCE POLICY, AS SET FORTH IN  THIS  PARAGRAPH,  the  insurer  shall
issue  a dividend or credit against future premiums for all policy hold-
ers with that policy form in an amount sufficient  to  assure  that  the
aggregate benefits paid in the previous calendar year plus the amount of
the dividends and credits shall equal seventy-five percent of the aggre-
gate  premiums collected for [the] AN INDIVIDUAL HEALTH INSURANCE policy
form AND EIGHTY PERCENT OF THE AGGREGATE PREMIUM COLLECTED FOR  A  SMALL
GROUP  HEALTH  INSURANCE  POLICY FORM in the previous calendar year. The
dividend or credit shall be issued to each policy which was in effect as
of December thirty-first of the applicable year [and remains  in  effect

S. 3062                             3

as  of  the  date  the  dividend or credit is issued]. All dividends and
credits must be distributed by September thirtieth of the year following
the calendar year in which the loss ratio requirements were  not  satis-
fied.  AN INSURER SHALL MAKE A REASONABLE EFFORT TO IDENTIFY THE CURRENT
ADDRESS  OF  THOSE  POLICY HOLDERS WHO ARE NO LONGER POLICY HOLDERS WHEN
THE DIVIDEND OR CREDIT IS ISSUED. The annual  report  required  by  this
paragraph  shall  include  an insurer's calculation of the dividends and
credits, as well as an explanation of the insurer's plan to issue  divi-
dends  or  credits.  The  instructions  and  format  for calculating and
reporting loss ratios and issuing dividends or credits shall  be  speci-
fied  by  the  superintendent  by  regulation.    Such regulations shall
include provisions for the distribution of a dividend or credit  in  the
event of cancellation or termination by a policy holder.
  (C)  DIRECT  CLAIMS  INCURRED FOR USE IN TESTING LOSS RATIO COMPLIANCE
UNDER THIS PARAGRAPH SHALL BE CALCULATED AS FOLLOWS: (I) THE CLAIMS PAID
DURING THE REPORTING CALENDAR YEAR; PLUS (II) CAPITATION  PAYMENTS  PAID
FOR  SERVICES  TO  BE  RENDERED DURING THE REPORTING CALENDAR YEAR; PLUS
(III) THE UNPAID CLAIM RESERVE AT THE END OF THE REPORTING CALENDAR YEAR
WHICH SHALL BE CALCULATED AS THE SUM OF CLAIMS PAID FROM  JANUARY  FIRST
THROUGH  JUNE FIRST OF THE YEAR FOLLOWING THE REPORTING CALENDAR YEAR ON
CLAIMS INCURRED IN THE REPORTING CALENDAR YEAR OR PRIOR YEARS, PLUS  THE
UNPAID CLAIMS RESERVE AS OF JUNE FIRST OF THE YEAR FOLLOWING THE REPORT-
ING  CALENDAR  YEAR ON CLAIMS INCURRED IN THE REPORTING CALENDAR YEAR OR
PRIOR YEARS DETERMINED FROM CLAIMS PAYMENTS THROUGH JUNE  FIRST  OF  THE
YEAR  FOLLOWING THE REPORTING CALENDAR YEAR; MINUS (IV) THE UNPAID CLAIM
RESERVE AT THE BEGINNING OF THE REPORTING CALENDAR YEAR WHICH  SHALL  BE
CALCULATED AS THE SUM OF THE CLAIMS PAID FROM JANUARY FIRST THROUGH JUNE
FIRST  OF  THE  REPORTING  CALENDAR YEAR ON CLAIMS INCURRED PRIOR TO THE
REPORTING CALENDAR YEAR, PLUS THE UNPAID CLAIMS RESERVE AS OF JUNE FIRST
OF THE REPORTING CALENDAR YEAR ON CLAIMS INCURRED PRIOR TO THE REPORTING
CALENDAR YEAR DETERMINED FROM CLAIM PAYMENTS THROUGH JUNE FIRST  OF  THE
REPORTING  YEAR; PLUS OR MINUS (V) THE EFFECTS FOR THE REPORTING YEAR OF
THE MARKET STABILIZATION POOLS; MINUS (VI) THE EFFECTS FOR THE REPORTING
YEAR OF THE STOP-LOSS POOLS.  NOTHING IN THIS SECTION SHALL BE CONSTRUED
TO PROHIBIT THE SUPERINTENDENT FROM REVIEWING CLAIMS  DATA  BEYOND  JUNE
FIRST.
  (D)  (I)  ANY  INSURER  THAT  VIOLATES  THE PROVISIONS OF THIS SECTION
INCLUDING, BUT NOT LIMITED TO, ANY FAILURE  TO  PROVIDE  A  DIVIDEND  OR
CREDIT TO SUBSCRIBERS AS REQUIRED BY SUBPARAGRAPH (B) OF THIS PARAGRAPH,
SHALL BE SUBJECT TO THE MAXIMUM PENALTIES PROVIDED IN THIS CHAPTER.
  (II)  IN  ADDITION TO THE PENALTIES OTHERWISE IMPOSED PURSUANT TO THIS
CHAPTER, WHERE AN INSURER ELECTING TO ADJUST PREMIUMS  PURSUANT  TO  THE
ALTERNATE  PROCEDURE SET FORTH IN SUBPARAGRAPH (A) OF THIS PARAGRAPH, IS
DETERMINED BY THE SUPERINTENDENT TO HAVE, IN A MANNER  IN  VIOLATION  OF
THE  PROVISIONS  OF  THIS  SECTION,  MATERIALLY  MISREPRESENTED THE LOSS
RATIOS REQUIRED BY SUBPARAGRAPHS (A) AND (B) OF THIS  PARAGRAPH  IN  TWO
CONSECUTIVE  FILINGS,  AND IF, AT ANY TIME DURING A THREE YEAR PERIOD IN
WHICH SUCH MATERIAL VIOLATIONS OCCURRED, THE INSURER FAILED TO PROVIDE A
DIVIDEND OR CREDIT AS REQUIRED BY SUBPARAGRAPH (B)  OF  THIS  PARAGRAPH,
SUCH INSURER SHALL BE PRESUMED TO BE SUBSTANTIALLY NONCOMPLIANT WITH THE
REQUIREMENTS  OF  THIS  PARAGRAPH  AND THE SUPERINTENDENT SHALL, AFTER A
NOTICE AND A HEARING, HAVE THE AUTHORITY TO PROHIBIT SAID  INSURER  FROM
ADJUSTING  PREMIUMS PURSUANT TO THE ALTERNATE PROCEDURE FOR THE AFFECTED
POLICY FORMS FOR A PERIOD OF UP TO  THREE  YEARS,  COMMENCING  WITH  THE
SUPERINTENDENT'S NOTICE OF SUCH DETERMINATION. THIS PROHIBITION SHALL BE

S. 3062                             4

IN  ADDITION  TO  ANY OTHER PENALTIES THAT THE SUPERINTENDENT MAY IMPOSE
PURSUANT TO THIS CHAPTER.
  (E)  THE  ALTERNATE PROCEDURE SET FORTH IN THIS PARAGRAPH SHALL NOT BE
AVAILABLE TO ADJUST  NEWLY-APPROVED  PREMIUM  RATES  OR  RATES  RECENTLY
ADJUSTED THROUGH THE PRIOR APPROVAL PROCESS UNTIL THE EARLIER OF (I) THE
DEVELOPMENT  OF  SUFFICIENT  ACTUAL  CLAIMS  EXPERIENCE  TO  JUSTIFY THE
REQUESTED ADJUSTMENT, AS CERTIFIED BY A MEMBER OF THE  AMERICAN  ACADEMY
OF  ACTUARIES  OR  OTHER INDIVIDUAL ACCEPTABLE TO THE SUPERINTENDENT, OR
(II) TWELVE MONTHS FROM THE PRIOR APPROVAL. PROVIDED HOWEVER, NOTHING IN
THIS SUBPARAGRAPH SHALL BE CONSTRUED TO PROHIBIT AN INSURER FROM UTILIZ-
ING THE ALTERNATE PROCEDURE TO ADJUST RATES ON A POLICY WHERE THE  RATES
FOR A RIDER TO THAT POLICY HAVE NOT BEEN IN EFFECT FOR TWELVE MONTHS.
  S  3.  Subsections (a), (b), (c), (d), (e), (f), (g), (h), (i) and (j)
of section 4308 of the insurance law  are  relettered  subsections  (b),
(c),  (d), (e), (f), (g), (h), (i), (j) and (k) and a new subsection (a)
is added to read as follows:
  (A) DEFINITIONS. FOR PURPOSES OF THIS SECTION:
  (1) "CONTRACT FORM" SHALL MEAN A CONTRACT OR CONTRACTS AND  ASSOCIATED
RIDERS  WHOSE EXPERIENCE HAS BEEN POOLED IN ORDER TO DETERMINE RATES FOR
EACH CONTRACT AND EACH RIDER;
  (2) "LOSS RATIO" SHALL MEAN THE RATIO OF DIRECT  CLAIMS  INCURRED  FOR
THE  REPORTING  CALENDAR  YEAR  TO  DIRECT  PREMIUMS EARNED FOR THE SAME
REPORTING CALENDAR YEAR, EXPRESSED AS A PERCENTAGE;
  (3) "DIRECT CLAIMS INCURRED" SHALL MEAN CLAIMS PAID DURING THE REPORT-
ING CALENDAR YEAR PLUS THE UNPAID CLAIMS  RESERVE  AT  THE  END  OF  THE
REPORTING CALENDAR YEAR AND CALCULATED CONSISTENT WITH PARAGRAPH FOUR OF
SUBSECTION (I) OF THIS SECTION;
  (4)  "DIRECT  PREMIUMS  EARNED" SHALL MEAN PREMIUMS WRITTEN DURING THE
REPORTING CALENDAR YEAR PLUS THE UNEARNED PREMIUMS AT THE  BEGINNING  OF
THE YEAR LESS THE UNEARNED PREMIUMS AT THE END OF THE YEAR, EXCLUSIVE OF
REINSURANCE ASSUMED OR CEDED; AND
  (5)  "SMALL  GROUP" SHALL MEAN A GROUP CONTRACT THAT IS SUBJECT TO THE
REQUIREMENTS OF SECTION FOUR THOUSAND THREE HUNDRED  SEVENTEEN  OF  THIS
ARTICLE.
  S  4.  Paragraph  1 of subsection (h) of section 4308 of the insurance
law, as added by chapter 504 of the laws of 1995 and such subsection  as
relettered by section three of this act, is amended to read as follows:
  (1) Beginning January first, nineteen hundred ninety-six, as an alter-
nate  procedure  to  the  requirements  of  subsection [(c)] (D) of this
section, a corporation subject to the provisions of this article  desir-
ing  to  increase  or decrease premiums for any contract subject to this
section may instead submit a rate filing or application  to  the  super-
intendent  and  such  application  or  filing  shall be deemed approved,
provided that (A) the anticipated incurred loss  ratio  for  a  contract
form  shall  not  be less than eighty-five percent for individual direct
payment contracts or [seventy-five] EIGHTY percent for small  group  and
small  group remittance contracts, nor, except in the case of individual
direct payment contracts with a loss ratio of greater than  one  hundred
five  percent  during nineteen hundred ninety-four, shall the loss ratio
for any direct payment, group or group remittance contract be more  than
one  hundred five percent of the anticipated earned premium, and (B) the
corporation submits, as part of such filing, a certification by a member
of the American Academy of Actuaries or other individual  acceptable  to
the superintendent that [that] THE corporation is in compliance with the
provisions  of  this  subsection,  based upon that person's examination,
including a review of the  appropriate  records  and  of  the  actuarial

S. 3062                             5

assumptions  and methods used by the corporation in establishing premium
rates for contracts subject to  this  section.  [For  purposes  of  this
section,  a  small  group  is any group whose contract is subject to the
requirements  of section forty-three hundred seventeen of this article.]
SUCH CERTIFICATION SHALL AFFIRM THAT  THE  RATE  FILING  OR  APPLICATION
SUBMITTED TO THE SUPERINTENDENT PURSUANT TO THIS SUBSECTION WAS PREPARED
IN  ACCORDANCE  WITH  GENERALLY  ACCEPTED  ACTUARIAL PRINCIPLES AND THIS
SECTION.   THE INSURER SHALL, AT  THE  REQUEST  OF  THE  SUPERINTENDENT,
PROVIDE  ADDITIONAL  UNDERLYING  ACTUARIAL  DOCUMENTATION TO SUPPORT THE
RATE FILING OR APPLICATION  PROVIDED,  HOWEVER,  THE  REQUEST  FOR  SUCH
INFORMATION SHALL NOT PRECLUDE THE PREMIUM RATE FROM GOING INTO EFFECT.
  S  5. Subsection (i) of section 4308 of the insurance law, as added by
chapter 504 of the laws of 1995 and as relettered by  section  three  of
this act, is amended to read as follows:
  (i) (1) Each calendar year, a corporation subject to the provisions of
this  article  shall  return, in the form of aggregate benefits incurred
for each contract form filed pursuant to  the  alternate  procedure  set
forth  in  subsection  [(g)]  (H)  of this section, at least eighty-five
percent for individual direct payment contracts or [seventy-five] EIGHTY
percent for small group  and  small  group  remittance  contracts,  but,
except  in  the  case of individual direct payment contracts with a loss
ratio of greater than one hundred five percent in nineteen hundred nine-
ty-four, for any direct payment, group or group remittance contract, not
in excess of one hundred five percent of the aggregate  premiums  earned
for  the  contract form during that calendar year.  IF A CORPORATION HAS
POOLED THE EXPERIENCE OF CONTRACTS AND/OR RIDERS TO DETERMINE THE PREMI-
UM RATES IN ACCORDANCE WITH APPLICABLE LAW, THE CORPORATION SHALL CALCU-
LATE THE LOSS RATIOS IN ACCORDANCE WITH THE MANNER IN  WHICH  IT  ESTAB-
LISHED THE PREMIUM RATES. Corporations subject to the provisions of this
article  shall annually report, no later than [May] AUGUST first of each
year, the loss ratio calculated pursuant to  this  subsection  for  each
such contract form for the previous calendar year.
  (2)  In  each  case  where the loss ratio for a contract form fails to
comply with the eighty-five percent minimum loss ratio  requirement  for
individual  direct  payment  contracts,  or  the  [seventy-five]  EIGHTY
percent minimum loss ratio requirement for small group and  small  group
remittance  contracts, as set forth in paragraph one of this subsection,
the corporation shall issue a dividend or credit against future premiums
for all contract holders with that contract form in an amount sufficient
to assure that the aggregate benefits incurred in the previous  calendar
year  plus  the  amount of the dividends and credits shall equal no less
than eighty-five percent for individual  direct  payment  contracts,  or
[seventy-five] EIGHTY percent for small group and small group remittance
contracts, of the aggregate premiums earned for the contract form in the
previous  calendar  year. The dividend or credit shall be issued to each
contract that was in effect as of December thirty-first of the  applica-
ble year [and remains in effect as of the date the dividend or credit is
issued].  All  dividends  and  credits  must be distributed by September
thirtieth of the year following the calendar  year  in  which  the  loss
ratio  requirements  were  not  satisfied.    A CORPORATION SHALL MAKE A
REASONABLE EFFORT TO IDENTIFY THE  CURRENT  ADDRESS  OF  THOSE  CONTRACT
HOLDERS  WHO  ARE NO LONGER CONTRACT HOLDERS WHEN THE DIVIDEND OR CREDIT
IS  ISSUED.  The  annual  report  required  by  paragraph  one  of  this
subsection  shall  include  a corporation's calculation of the dividends
and credits, as well as an explanation  of  the  corporation's  plan  to
issue  dividends or credits. The instructions and format for calculating

S. 3062                             6

and reporting loss ratios and issuing  dividends  or  credits  shall  be
specified  by  the superintendent by regulation.  Such regulations shall
include provisions for the distribution of a dividend or credit  in  the
event of cancellation or termination by a contract holder or subscriber.
  (3)  In  each  case  where the loss ratio for a contract form fails to
comply with the one hundred five percent maximum loss ratio  requirement
of  paragraph  one of this subsection, the corporation shall institute a
premium rate increase in an amount sufficient to assure that the  aggre-
gate benefits incurred in the previous calendar year shall equal no more
than  one  hundred  five  percent  of  the sum of the aggregate premiums
earned for the contract form in  the  previous  calendar  year  and  the
aggregate  premium  rate increase. The rate increase shall be applied to
each contract that was in effect as  of  December  thirty-first  of  the
applicable  year  and remains in effect as of the date the rate increase
is imposed. All rate increases must be imposed by September thirtieth of
the year following the calendar year in which the  loss  ratio  require-
ments were not satisfied. The annual report required by paragraph one of
this subsection shall include a corporation's calculation of the premium
rate  increase,  as  well as an explanation of the corporation's plan to
implement the rate increase. The instructions and format for calculating
and reporting loss ratios and implementing rate increases shall be spec-
ified by the superintendent by regulation.
  (4) DIRECT CLAIMS INCURRED FOR USE IN TESTING  LOSS  RATIO  COMPLIANCE
UNDER  THIS  SUBSECTION  SHALL  BE CALCULATED AS FOLLOWS: (I) THE CLAIMS
PAID DURING THE REPORTING CALENDAR YEAR; PLUS (II)  CAPITATION  PAYMENTS
PAID  FOR  SERVICES  TO  BE RENDERED DURING THE REPORTING CALENDAR YEAR;
PLUS (III) THE UNPAID CLAIM RESERVE AT THE END OF THE REPORTING CALENDAR
YEAR WHICH SHALL BE CALCULATED AS THE SUM OF CLAIMS  PAID  FROM  JANUARY
FIRST  THROUGH  JUNE  FIRST OF THE YEAR FOLLOWING THE REPORTING CALENDAR
YEAR ON CLAIMS INCURRED IN THE REPORTING CALENDAR YEAR OR  PRIOR  YEARS,
PLUS  THE  UNPAID  CLAIMS RESERVE AS OF JUNE FIRST OF THE YEAR FOLLOWING
THE REPORTING CALENDAR YEAR ON CLAIMS INCURRED IN THE REPORTING CALENDAR
YEAR OR PRIOR YEARS DETERMINED FROM CLAIMS PAYMENTS THROUGH  JUNE  FIRST
OF THE YEAR FOLLOWING THE REPORTING CALENDAR YEAR; MINUS (IV) THE UNPAID
CLAIM  RESERVE  AT  THE  BEGINNING  OF THE REPORTING CALENDAR YEAR WHICH
SHALL BE CALCULATED AS THE SUM OF THE CLAIMS  PAID  FROM  JANUARY  FIRST
THROUGH  JUNE  FIRST  OF  THE REPORTING CALENDAR YEAR ON CLAIMS INCURRED
PRIOR TO THE REPORTING CALENDAR YEAR, PLUS THE UNPAID CLAIMS RESERVE  AS
OF JUNE FIRST OF THE REPORTING CALENDAR YEAR ON CLAIMS INCURRED PRIOR TO
THE  REPORTING CALENDAR YEAR DETERMINED FROM CLAIM PAYMENTS THROUGH JUNE
FIRST OF THE REPORTING YEAR; PLUS OR  MINUS  (V)  THE  EFFECTS  FOR  THE
REPORTING YEAR OF THE MARKET STABILIZATION POOLS; MINUS (VI) THE EFFECTS
FOR  THE REPORTING YEAR OF THE STOP-LOSS POOLS.  NOTHING IN THIS SECTION
SHALL BE CONSTRUED TO PROHIBIT THE SUPERINTENDENT FROM REVIEWING  CLAIMS
DATA BEYOND JUNE FIRST.
  S  6.  Section  4308 of the insurance law is amended by adding two new
subsections (l) and (m) to read as follows:
  (1) (I) ANY INSURER THAT  VIOLATES  THE  PROVISIONS  OF  THIS  SECTION
INCLUDING,  BUT  NOT  LIMITED  TO,  ANY FAILURE TO PROVIDE A DIVIDEND OR
CREDIT TO SUBSCRIBERS AS REQUIRED BY SUBSECTION  (I)  OF  THIS  SECTION,
SHALL BE SUBJECT TO THE MAXIMUM PENALTIES PROVIDED IN THIS CHAPTER.
  (II)  IN  ADDITION TO THE PENALTIES OTHERWISE IMPOSED PURSUANT TO THIS
CHAPTER, WHERE AN INSURER ELECTING TO ADJUST PREMIUMS  PURSUANT  TO  THE
ALTERNATE  PROCEDURE  SET  FORTH  IN  SUBSECTION (H) OF THIS SECTION, IS
DETERMINED BY THE SUPERINTENDENT TO HAVE, IN A MANNER  IN  VIOLATION  OF
THE  PROVISIONS  OF  THIS  SECTION,  MATERIALLY  MISREPRESENTED THE LOSS

S. 3062                             7

RATIOS REQUIRED BY SUBSECTIONS (H)  AND  (I)  OF  THIS  SECTION  IN  TWO
CONSECUTIVE  FILINGS,  AND IF, AT ANY TIME DURING A THREE YEAR PERIOD IN
WHICH SUCH MATERIAL VIOLATIONS OCCURRED, THE INSURER FAILED TO PROVIDE A
DIVIDEND  OR  CREDIT AS REQUIRED BY SUBSECTION (I) OF THIS SECTION, SUCH
INSURER SHALL BE PRESUMED TO  BE  SUBSTANTIALLY  NONCOMPLIANT  WITH  THE
REQUIREMENTS  OF  THIS  PARAGRAPH  AND THE SUPERINTENDENT SHALL, AFTER A
NOTICE AND A HEARING, HAVE THE AUTHORITY TO PROHIBIT SAID  INSURER  FROM
ADJUSTING  PREMIUMS PURSUANT TO THE ALTERNATE PROCEDURE FOR THE AFFECTED
POLICY FORMS FOR A PERIOD OF UP TO  THREE  YEARS,  COMMENCING  WITH  THE
SUPERINTENDENT'S NOTICE OF SUCH DETERMINATION. THIS PROHIBITION SHALL BE
IN  ADDITION  TO  ANY OTHER PENALTIES THAT THE SUPERINTENDENT MAY IMPOSE
PURSUANT TO THIS CHAPTER.
  (M) THE ALTERNATE PROCEDURE  SET  FORTH  IN  SUBSECTION  (H)  OF  THIS
SECTION SHALL NOT BE AVAILABLE TO ADJUST NEWLY-APPROVED PREMIUM RATES OR
RATES  RECENTLY  ADJUSTED  THROUGH  THE PRIOR APPROVAL PROCESS UNTIL THE
EARLIER OF (I) THE DEVELOPMENT OF SUFFICIENT ACTUAL CLAIMS EXPERIENCE TO
JUSTIFY THE REQUESTED ADJUSTMENT, AS CERTIFIED BY A MEMBER OF THE AMERI-
CAN ACADEMY OF ACTUARIES OR OTHER INDIVIDUAL ACCEPTABLE  TO  THE  SUPER-
INTENDENT,  OR  (II)  TWELVE  MONTHS  FROM  THE PRIOR APPROVAL. PROVIDED
HOWEVER, NOTHING IN THIS SUBSECTION SHALL BE CONSTRUED  TO  PROHIBIT  AN
INSURER  FROM  UTILIZING  THE  ALTERNATE  PROCEDURE TO ADJUST RATES ON A
POLICY WHERE THE RATES FOR A RIDER TO  THAT  POLICY  HAVE  NOT  BEEN  IN
EFFECT FOR TWELVE MONTHS.
  S  7. Subsection (g) of section 4308 of the insurance law, as added by
chapter 501 of the laws of 1992 and as relettered by  section  three  of
this act, is amended to read as follows:
  (g)  The  results of any audit conducted pursuant to subsections [(d)]
(E) and [(e)] (F) of this section shall be provided to  the  corporation
and  each  member  of  its board of directors.  The superintendent shall
have the authority to direct the corporation in writing to implement any
recommendations resulting from the audit that the  superintendent  finds
to  be necessary and reasonable; provided, however, that the superinten-
dent shall first consider any written response submitted by  the  corpo-
ration  or the board of directors prior to making such finding. Upon any
application for a rate adjustment by the corporation, the superintendent
shall review the corporation's compliance with the directions and recom-
mendations made previously by the superintendent, as  a  result  of  the
most  recently completed management or financial audit and shall include
such findings in any written decision concerning such application.
  S 8. Paragraph 1 of subsection (i) and  subsections  (j)  and  (k)  of
section  4308  of the insurance law, as added by chapter 504 of the laws
of 1995 and such subsections as relettered by section three of this act,
are amended to read as follows:
  (1) Each calendar year, a corporation subject  to  the  provisions  of
this  article  shall  return, in the form of aggregate benefits incurred
for each contract form filed pursuant to  the  alternate  procedure  set
forth  in  subsection  [(g)]  (H)  of this section, at least eighty-five
percent for individual direct payment contracts or [seventy-five] EIGHTY
percent for small group  and  small  group  remittance  contracts,  but,
except  in  the  case of individual direct payment contracts with a loss
ratio of greater than one hundred five percent in nineteen hundred nine-
ty-four, for any direct payment, group or group remittance contract, not
in excess of one hundred five percent of the aggregate  premiums  earned
for  the  contract form during that calendar year.  IF A CORPORATION HAS
POOLED THE EXPERIENCE OF CONTRACTS AND/OR RIDERS TO DETERMINE THE PREMI-
UM RATES IN ACCORDANCE WITH APPLICABLE LAW, THE CORPORATION SHALL CALCU-

S. 3062                             8

LATE THE LOSS RATIOS IN ACCORDANCE WITH THE MANNER IN  WHICH  IT  ESTAB-
LISHED THE PREMIUM RATES. Corporations subject to the provisions of this
article  shall annually report, no later than [May] AUGUST first of each
year,  the  loss  ratio  calculated pursuant to this subsection for each
such contract form for the previous calendar year.
  (j) The alternate procedure described in subsections [(g) and] (h) AND
(I) of this section shall apply to individual direct  payment  contracts
issued  pursuant  to sections four thousand three hundred twenty-one and
four thousand three hundred twenty-two of  this  article  on  and  after
January first, nineteen hundred ninety-seven.
  (k)  The  eighty-five percent minimum loss ratio for individual direct
payment contracts described in subsections [(g) and] (h) AND (I) of this
section shall be reduced to eighty-two and one-half percent as of  Janu-
ary first, nineteen hundred ninety-seven and shall be further reduced to
eighty  percent  as  of January first, nineteen hundred ninety-eight and
thereafter. The refund or credit requirements for failure to meet  mini-
mum loss ratios will continue, but at these reduced percentages.
  S 9. Subsection (i) of section 3216 of the insurance law is amended by
adding a new paragraph 26 to read as follows:
  (26)(A) NO MANAGED CARE HEALTH INSURANCE POLICY THAT PROVIDES COVERAGE
FOR  HOSPITAL, MEDICAL OR SURGICAL CARE SHALL PROVIDE THAT SERVICES OF A
PARTICIPATING HOSPITAL WILL BE COVERED AS OUT-OF-NETWORK SERVICES SOLELY
ON THE BASIS THAT THE ADMITTING PHYSICIAN OR TREATING PHYSICIAN IS NOT A
PARTICIPATING PROVIDER.
  (B) NO MANAGED CARE HEALTH INSURANCE POLICY THAT PROVIDES COVERAGE FOR
HOSPITAL, MEDICAL OR SURGICAL CARE SHALL  PROVIDE  THAT  SERVICES  OF  A
PARTICIPATING PHYSICIAN WILL BE COVERED AS OUT-OF-NETWORK SERVICES SOLE-
LY  ON  THE  BASIS THAT THE SERVICES ARE RENDERED IN A NON-PARTICIPATING
HOSPITAL.
  (C) FOR PURPOSES OF THIS PARAGRAPH, A "MANAGED CARE  HEALTH  INSURANCE
POLICY" IS A POLICY THAT REQUIRES THAT SERVICES BE PROVIDED BY A PROVID-
ER  PARTICIPATING  IN  THE INSURER'S NETWORK IN ORDER FOR THE INSURED TO
RECEIVE THE MAXIMUM LEVEL OF REIMBURSEMENT UNDER THE POLICY.
  S 10. Subsection (k) of section 3221 of the insurance law  is  amended
by adding a new paragraph 15 to read as follows:
  (15)(A)  NO GROUP OR BLANKET MANAGED CARE HEALTH INSURANCE POLICY THAT
PROVIDES COVERAGE FOR HOSPITAL, MEDICAL OR SURGICAL CARE  SHALL  PROVIDE
THAT SERVICES OF A PARTICIPATING HOSPITAL WILL BE COVERED AS OUT-OF-NET-
WORK SERVICES SOLELY ON THE BASIS THAT THE ADMITTING PHYSICIAN OR TREAT-
ING PHYSICIAN IS NOT A PARTICIPATING PROVIDER.
  (B)  NO  GROUP  OR  BLANKET  MANAGED CARE HEALTH INSURANCE POLICY THAT
PROVIDES COVERAGE FOR HOSPITAL, MEDICAL OR SURGICAL CARE  SHALL  PROVIDE
THAT   SERVICES   OF  A  PARTICIPATING  PHYSICIAN  WILL  BE  COVERED  AS
OUT-OF-NETWORK SERVICES SOLELY  ON  THE  BASIS  THAT  THE  SERVICES  ARE
RENDERED IN A NON-PARTICIPATING HOSPITAL.
  (C)  FOR  PURPOSES OF THIS PARAGRAPH, A "MANAGED CARE HEALTH INSURANCE
POLICY" IS A POLICY THAT REQUIRES THAT SERVICES BE PROVIDED BY A PROVID-
ER PARTICIPATING IN THE INSURER'S NETWORK IN ORDER FOR  THE  INSURED  TO
RECEIVE THE MAXIMUM LEVEL OF REIMBURSEMENT UNDER THE POLICY.
  S  11.  Section  4303  of the insurance law is amended by adding a new
subsection (ff) to read as follows:
  (FF) (1) NO MANAGED CARE CONTRACT ISSUED BY A  HEALTH  SERVICE  CORPO-
RATION, HOSPITAL SERVICE CORPORATION OR MEDICAL EXPENSE INDEMNITY CORPO-
RATION  THAT  PROVIDES  COVERAGE  FOR HOSPITAL, MEDICAL OR SURGICAL CARE
SHALL PROVIDE THAT SERVICES OF A PARTICIPATING HOSPITAL WILL BE  COVERED

S. 3062                             9

AS OUT-OF-NETWORK SERVICES SOLELY ON THE BASIS THAT THE ADMITTING PHYSI-
CIAN OR TREATING PHYSICIAN IS NOT A PARTICIPATING PROVIDER.
  (2)  NO  MANAGED CARE CONTRACT ISSUED BY A HEALTH SERVICE CORPORATION,
HOSPITAL SERVICE CORPORATION OR MEDICAL  EXPENSE  INDEMNITY  CORPORATION
THAT  PROVIDES  COVERAGE  FOR  HOSPITAL,  MEDICAL OR SURGICAL CARE SHALL
PROVIDE THAT SERVICES OF A PARTICIPATING PHYSICIAN WILL  BE  COVERED  AS
OUT-OF-NETWORK  SERVICES  SOLELY  ON  THE  BASIS  THAT  THE SERVICES ARE
RENDERED IN A NON-PARTICIPATING HOSPITAL.
  (3) FOR PURPOSES OF THIS SUBSECTION, A "MANAGED CARE  CONTRACT"  IS  A
CONTRACT  THAT  REQUIRES THAT SERVICES BE PROVIDED BY A PROVIDER PARTIC-
IPATING IN THE CORPORATION'S NETWORK IN  ORDER  FOR  THE  SUBSCRIBER  TO
RECEIVE THE MAXIMUM LEVEL OF REIMBURSEMENT UNDER THE CONTRACT.
  S  12.  Subdivisions 3 and 4 of section 4406 of the public health law,
subdivision 3 as renumbered by chapter 538 of  the  laws  of  1993,  are
renumbered subdivisions 4 and 5 and a new subdivision 3 is added to read
as follows:
  3.  (A) NO CONTRACT ISSUED PURSUANT TO THIS SECTION SHALL PROVIDE THAT
SERVICES OF A PARTICIPATING HOSPITAL WILL BE COVERED  AS  OUT-OF-NETWORK
SERVICES  SOLELY  ON  THE BASIS THAT THE ADMITTING PHYSICIAN OR TREATING
PHYSICIAN IS NOT A PARTICIPATING PROVIDER.
  (B) NO CONTRACT ISSUED PURSUANT TO THIS  SECTION  SHALL  PROVIDE  THAT
SERVICES  OF A PARTICIPATING PHYSICIAN WILL BE COVERED AS OUT-OF-NETWORK
SERVICES SOLELY ON THE  BASIS  THAT  THE  SERVICES  ARE  RENDERED  IN  A
NON-PARTICIPATING HOSPITAL.
  S  13.  Subsection  (a)  of  section  3224-a  of the insurance law, as
amended by chapter 666 of the laws  of  1997,  is  amended  to  read  as
follows:
  (a)  Except  in a case where the obligation of an insurer or an organ-
ization or corporation licensed or certified pursuant to article  forty-
three  of this chapter or article forty-four of the public health law to
pay a claim submitted by a policyholder or  person  covered  under  such
policy  or  make  a  payment to a health care provider is not reasonably
clear, or when there is a reasonable basis supported by specific  infor-
mation  available  for  review  by the superintendent that such claim or
bill for health care services rendered was submitted fraudulently,  such
insurer  or organization or corporation shall pay the claim to a policy-
holder or covered person or make a payment to  a  health  care  provider
WITHIN  TWENTY-ONE  DAYS  OF  RECEIPT  OF  A  CLAIM OR BILL FOR SERVICES
RENDERED THAT IS SUBMITTED BY ELECTRONIC  MEANS  AND  within  forty-five
days of receipt of a claim or bill for services rendered THAT IS SUBMIT-
TED OTHER THAN BY ELECTRONIC MEANS, SUCH AS BY PAPER OR FACSIMILE.
  S 14. The opening paragraph of subsection (b) of section 3224-a of the
insurance law, as amended by chapter 666 of the laws of 1997, is amended
to read as follows:
  In  a  case  where  the obligation of an insurer or an organization or
corporation licensed or certified pursuant  to  article  forty-three  of
this  chapter  or  article  forty-four of the public health law to pay a
claim or make a payment for health care services rendered is not reason-
ably clear due to a good faith dispute regarding the  eligibility  of  a
person  for coverage, the liability of another insurer or corporation or
organization for all or part of the claim, the amount of the claim,  the
benefits  covered  under a contract or agreement, or the manner in which
services were accessed or provided, an insurer or organization or corpo-
ration shall pay any undisputed portion of the claim in accordance  with
this  subsection  and  notify the policyholder, covered person or health
care provider in writing WITHIN FOURTEEN CALENDAR DAYS OF RECEIPT  OF  A

S. 3062                            10

CLAIM  SUBMITTED  BY ELECTRONIC MEANS AND within thirty calendar days of
receipt of [the] A claim THAT IS  SUBMITTED  BY  OTHER  THAN  ELECTRONIC
MEANS, SUCH AS BY PAPER OR FACSIMILE:
  S 15. This act shall take effect immediately; provided, however, that:
  (a)  sections  one through eight of this act shall take effect January
1, 2010 and shall apply to premium rate changes effective on  and  after
that  date  and  to loss ratio reports required to be filed beginning in
2011;
  (b) sections nine through twelve of this act shall take effect January
1, 2010 and shall apply to policies and contracts issued, renewed, modi-
fied, altered and amended on and after such  effective  date,  provided,
further,  that any policies and contracts to which sections nine through
twelve of this act apply and that were approved by the superintendent of
insurance shall be deemed to comply with all applicable laws  and  regu-
lations until January 1, 2010; and
  (c) sections thirteen and fourteen of this act shall take effect Janu-
ary  1,  2010  and shall apply to claims transmitted and received on and
after such date.

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Senate Bill S3062

Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

co-Sponsors

2009-S3062 (ACTIVE) - Details

2009-S3062 (ACTIVE) - Summary

2009-S3062 (ACTIVE) - Sponsor Memo

2009-S3062 (ACTIVE) - Bill Text download pdf

Comments

Senate Bill S3062

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Sponsored By

James L. Seward

Archive: Last Bill Status - In Senate Committee Insurance Committee

co-Sponsors

Dale M. Volker

2009-S3062 (ACTIVE) - Details

2009-S3062 (ACTIVE) - Summary

2009-S3062 (ACTIVE) - Sponsor Memo

2009-S3062 (ACTIVE) - Bill Text download pdf

Comments