Legislation
SECTION 4304
Individual contracts
Insurance (ISC) CHAPTER 28, ARTICLE 43
§ 4304. Individual contracts. (a) Every corporation subject to the
provisions of this article may issue a contract to an individual the
premiums for which may be paid to the corporation directly by the
individual or by a remitting agent for the group to which the individual
belongs. If the premiums for a contract issued pursuant to this section
are paid to the corporation by a remitting agent, such contract shall be
subject to subsections (k) and (l) of section four thousand two hundred
thirty-five of this chapter, and for the purposes of these subsections,
the remitting agent shall be treated as the policyholder.
(b)(1) Any such contract shall be for a period not in excess of twelve
months, but no contract shall be made providing for the inception of
benefits at a date later than one year from the date of the contract.
(2) Any such contract shall provide that it will be automatically
renewed from year to year unless there shall have been one month's prior
written notice of termination by the subscriber.
(3) No corporation shall refuse to renew any such contract because of
the physical or mental condition or the health of any person covered
thereunder. The provisions of this subsection shall in no way diminish
the rights of individuals pursuant to section four thousand three
hundred seventeen of this article.
(c) Any such contract may be terminated in the following manner:
(1) At the option of the individual to whom the contract is issued,
upon not less than one month's prior written notice.
(2) At the option of the corporation, for one or more of the following
reasons:
(A) The individual has failed to pay premiums or contributions in
accordance with the terms of the contract or the corporation has not
received timely premium payments.
(B) The individual has performed an act or practice that constitutes
fraud or made an intentional misrepresentation of material fact under
the terms of the contract, upon not less than one month's prior written
notice.
(C) (i) Discontinuance of a class of contract upon not less than
ninety days' prior written notice. In exercising the option to
discontinue coverage pursuant to this item, the corporation must act
uniformly without regard to any health status-related factor of enrolled
individuals or individuals who may become eligible for such coverage and
must offer to subscribers or group remitting agents, as may be
appropriate, the option to purchase all other individual health
insurance coverage currently being offered by the corporation to
applicants in that market. Provided, however, the superintendent may,
after giving due consideration to the public interest, approve a request
made by a corporation for the corporation to satisfy the requirements of
this item through the offering of contracts at each level of coverage as
defined in subsection (b) of section four thousand three hundred six-h
of this article that contains the essential health benefits package
described in paragraph three of subsection (e) of section four thousand
three hundred six-h of this article by another corporation, insurer or
health maintenance organization within the corporation's same holding
company system, as defined in article fifteen of this chapter.
(ii) Discontinuance of all hospital, surgical or medical expense
coverage in the individual direct payment market in this state upon
written notice to the superintendent and to each subscriber not less
than one hundred eighty days prior to the date of the expiration of such
coverage. In the event of such a withdrawal from the individual direct
payment market, the corporation must also provide the superintendent
with a written plan to minimize potential disruption in the marketplace
occasioned by such withdrawal. In addition, the corporation may not
provide for the issuance of any hospital, surgical or medical expense
coverage in the individual direct payment market in this state during
the five-year period beginning on the date of the discontinuance of the
last health insurance coverage not so renewed.
(iii) Discontinuance of all individual hospital, surgical or medical
expense insurance contracts for which the premiums are paid by a
remitting agent of a group, in the small group market, or the large
group market, or both markets, in this state, in conjunction with a
withdrawal from the small group market, or the large group market, or
both markets, in this state. Withdrawal from the small group market, or
the large group market, or both markets, shall be governed by the
requirements of subparagraphs (E) and (F) of paragraph three of
subsection (j) of section four thousand three hundred five of this
article. For purposes of this item, "withdrawal" from a market means
that no coverage is offered or maintained in such market under contracts
issued pursuant to this section or contracts issued pursuant to section
four thousand three hundred five of this article.
(D) In the case of a corporation that offers health insurance in the
market through a network plan, the individual no longer resides, lives
or works in the service area (or in an area for which the corporation is
authorized to do business) but only if such coverage is terminated under
this paragraph uniformly without regard to any health status-related
factor of covered individuals. For the purposes of this subparagraph,
the term "network plan" means health insurance coverage of a corporation
organized under this article under which the financing and delivery of
health care (including items and services paid for as such care) are
provided, in whole or in part, through a defined set of providers under
contract either with the corporation or another entity that has
contracted with the corporation.
(E) In case of a contract for which the premiums are paid by a
remitting agent of a group, discontinuance of the individual's
membership in such group.
(F) Such other reasons as the superintendent may approve and
authorized by the Health Insurance Portability and Accountability Act of
1996, Public Law 104-191, and any later amendments or successor
provisions, or by any federal regulations or rules that implement the
provisions of the Act, upon not less than one month's prior written
notice.
(3) Every notice of termination shall be in a form satisfactory to the
superintendent and shall include a statement of the conversion
privileges, if any, upon such termination.
(4) In the event of termination of a contract, the corporation shall
return the unearned portion of the premium.
(d) (1) (A) No contract issued pursuant to this section shall entitle
more than one person to benefits except that a contract issued and
marked as a "family contract" may provide that benefits will be
furnished to the contract holder, spouse, dependent child or children,
or other person chiefly dependent upon the contract holder provided
that:
(i) A "family contract" may provide coverage to any child or children
not over nineteen years of age, provided that an unmarried student at an
accredited institution of learning may be considered a dependent until
the child becomes twenty-three years of age, and provided also that the
coverage of any such "family contract" may include, at the option of the
corporation, any unmarried child until attaining age twenty-five.
However, a "family contract" of hospital, medical, surgical, or
prescription drug expense insurance that provides coverage for dependent
children shall provide such coverage to a married or unmarried child
until attainment of age twenty-six without regard to financial
dependence, residency with the contract holder, student status, or
employment.
(ii) The coverage of any such "family contract" shall include any
other unmarried child, regardless of age, who is incapable of
self-sustaining employment by reason of mental illness, developmental
disability, as defined in the mental hygiene law, or physical handicap
and who became so incapable prior to attainment of the age at which
coverage would otherwise terminate.
(B) In addition to the requirements of subparagraph (A) of this
paragraph, every corporation issuing a contract of hospital, medical or
surgical expense insurance that provides coverage for children must make
available and if requested by the contractholder, extend coverage under
the contract to an unmarried child through age twenty-nine, without
regard to financial dependence who is not insured by or eligible for
coverage under any employer health benefit plan as an employee or
member, whether insured or self-insured, and who lives, works or resides
in New York state or the service area of the corporation. Such coverage
shall be made available at the inception of all new contracts, and for
group remittance contracts at any anniversary date. Written notice of
the availability of such coverage shall be delivered to the
contractholder prior to the inception of such contract, and for group
remittance contracts annually thereafter.
(C) Notwithstanding any rule, regulation or law to the contrary, any
"family contract" shall provide that coverage of newborn infants,
including newly born infants adopted by the subscriber if such
subscriber takes physical custody of the infant upon such infant's
release from the hospital and files a petition pursuant to section one
hundred fifteen-c of the domestic relations law within thirty days of
birth; and provided further that no notice of revocation to the adoption
has been filed pursuant to section one hundred fifteen-b of the domestic
relations law and consent to the adoption has not been revoked, shall be
effective from the moment of birth for injury or sickness including the
necessary care and treatment of medically diagnosed congenital defects
and birth abnormalities including premature birth, except that in cases
of adoption, coverage of the initial hospital stay shall not be required
where a birth parent has insurance coverage available for the infant's
care. This provision regarding coverage of newborn infants shall not
apply to two person coverage. In the case of individual or two person
coverages the corporation must also permit the person to whom the
contract is issued to elect such coverage of newborn infants from the
moment of birth. If notification and/or payment of an additional premium
or contribution is required to make coverage effective for a newborn
infant, the coverage may provide that such notice and/or payment be made
within no less than thirty days of the day of birth to make coverage
effective from the moment of birth. This election shall not be required
in the case of student insurance or where the group remitting agent's
plan does not provide coverage for children.
(2) Every "family contract" under which coverage of a dependent spouse
or contract holder would terminate upon such spouse or contract holder
attaining the age prescribed in subchapter XVIII of the Social Security
Act, 42 U.S.C. § 1395 et seq ("Medicare"), as the age of first
eligibility for the benefits provided by such law shall not so
terminate, if such dependent spouse is not eligible for all of such
benefits, for as long as the contract remains in force and such
dependent spouse remains ineligible to receive any of such "medicare"
benefits, provided proof of such ineligibility is submitted to the
corporation within thirty-one days of the date notice of termination of
coverage is mailed by the corporation to the last known address of the
such spouse or contract holder.
(3) Coverage of an unmarried dependent child who is incapable of
self-sustaining employment by reason of mental illness, developmental
disability, as defined in the mental hygiene law, or physical handicap
and who became so incapable prior to attainment of the age at which
coverage would otherwise terminate and who is chiefly dependent upon the
contract holder for support and maintenance, shall not terminate while
the contract remains in force and the child remains in such condition,
if the contract holder has within thirty-one days of such child's
attainment of the limiting age submitted proof of such child's
incapacity as described herein.
(e) (1) (A) If any such contract is terminated in accordance with the
provisions of paragraph one of subsection (c) of this section, or any
such contract is terminated because of a default by the remitting agent
in the payment of premiums not cured within the grace period and the
remitting agent has not replaced the contract with similar and
continuous coverage for the same group whether insured or self-insured,
or any such contract is terminated in accordance with the provisions of
subparagraph (E) of paragraph two of subsection (c) of this section, or
if an individual other than the contract holder is no longer covered
under a "family contract" because the individual is no longer within the
definition set forth in the contract, or a spouse is no longer covered
under the contract because of divorce from the contract holder or
annulment of the marriage, or any such contract is terminated because of
the death of the contract holder, then such individual, former spouse,
or in the case of the death of the contract holder the surviving spouse
or other dependents of the deceased contract holder covered under the
contract, as the case may be, shall be entitled to convert, without
evidence of insurability, upon application therefor and the making of
the first payment thereunder within sixty days after the date of
termination of such contract, to a contract that contains the essential
health benefits package described in paragraph three of subsection (e)
of section four thousand three hundred six-h of this article.
(B) The corporation shall offer one contract at each level of coverage
as defined in subsection (b) of section four thousand three hundred
six-h of this article. The individual may choose any such contract
offered by the corporation. Provided, however, the superintendent may,
after giving due consideration to the public interest, approve a request
made by a corporation for the corporation to satisfy the requirements of
this paragraph through the offering of contracts that comply with this
paragraph by another corporation, insurer or health maintenance
organization within the corporation's same holding company system, as
defined in article fifteen of this chapter.
(C) The effective date of the coverage provided by the converted
direct payment contract shall be the date of the termination of coverage
under the contract from which conversion was made.
(2) The corporation shall not be required to issue any such converted
individual direct payment contract if its issuance would result in
overinsurance or duplication of benefits according to standards on file
with the superintendent and approved by the superintendent with regard
to such contracts.
(3) In addition to the right of conversion herein, the employee or
member insured under a contract for which the premiums are paid by a
remitting agent of a group shall at his option, as an alternative to
conversion, be entitled to have his coverage continued under the group
remittance contract in accordance with the conditions and limitations
contained in subsection (k) of this section, and have issued at the end
of the period of continuation an individual direct payment conversion
contract subject to the terms of this subsection. The effective date for
the conversion contract shall be the day following the termination of
insurance under the group remittance contract, or if there is a
continuation of coverage, on the day following the end of the period of
continuation.
(4) For purposes of this subsection, the term "dependent" shall
include a child as described in subsection (d) of this section.
(f) No such corporation shall require as a condition for renewal or
for failure to cancel any individual contract any rider, endorsement or
other attachment which shall limit the nature or extent of the benefits
thereunder, except that a corporation may at any time upon at least
thirty days' prior written notice amend such contract to provide a
different level of benefits thereunder if approved by the superintendent
on finding, upon application by the corporation at least four months
before the proposed effective date, that such level would exceed, in the
aggregate, the level of benefits theretofore provided and would be in
the best interests of the corporation and the persons covered under such
contracts.
(g) The provisions of this section with respect to limitations on the
termination of an individual contract shall not apply to a contract or
an endorsement or rider thereto which is issued by a corporation subject
to the provisions of this article pursuant to a plan providing for
experimentation in new forms of benefits in the field of health
insurance protection, which plan shall be submitted in writing to the
superintendent. The superintendent shall approve such plan if he finds
that the benefits are of the type heretofore described and that the
issuance of such contract, endorsement or rider is in the public
interest. Approval of such contract, rider or endorsement shall be
subject to any conditions which may be prescribed by the superintendent,
including, but not limited to, the maximum period during which the
exemption from the provisions of this section with respect to
termination shall continue. The superintendent may, for good cause
shown, extend such period of exemption. Any termination of such
contract, rider or endorsement during the period of exemption, other
than for non-payment of premium and fraud in applying for the contract,
shall be subject to the approval of the superintendent. Upon termination
of such contract, or termination of a rider or endorsement providing
experimental benefits, as aforesaid, the contract holder thereunder who
has at the time of such termination been covered continuously
immediately preceding such termination for a period of two years or more
under one or more contracts of the corporation shall be entitled to have
issued to him by the corporation, without evidence of insurability, upon
application therefor and the making of the first payment thereunder
within thirty-one days after the date of termination, an individual
direct payment contract of the type and class which the superintendent
shall determine provides benefits most nearly comparable to those
currently provided other individuals. If the corporation does not
terminate such contract or a rider or endorsement thereto providing
experimental benefits as aforesaid during the period of exemption, or
any extended period provided herein, such contract shall thereafter be
subject to the provisions of this section with respect to termination as
of the original effective date of such contract.
(h) Any contract, other than one issued in fulfillment of the
continuing care responsibilities of an operator of a continuing care
retirement community in accordance with article forty-six of the public
health law, made available because of residence in a particular
facility, housing development, or community shall contain the following
notice in twelve point type in bold face on the first page:
"NOTICE - THIS CONTRACT DOES NOT MEET THE REQUIREMENTS OF A CONTINUING
CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY
A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY."
(i) Any persons covered by the contract who are also members of a
reserve component of the armed forces of the United States, including
the National Guard, shall be entitled, upon written request, to have
their coverage suspended during a period of active duty as described
herein. The contract shall provide that the insurer will refund any
unearned premiums for the period of such suspension. Persons covered by
the contract shall be entitled to resumption of coverage, upon written
application and payment of the required premium within sixty days after
the date of termination of the period of active duty, with no
limitations or conditions imposed as a result of such period of active
duty except as set forth in paragraphs one and two herein. Coverage
shall be retroactive to the date of termination of the period of active
duty. Such right of resumption provided for herein shall be in addition
to other existing rights granted pursuant to state and federal laws and
regulations and shall not be deemed to qualify or limit such rights in
any way. No exclusion or waiting period may be imposed in connection
with coverage of a health or physical condition of a person entitled to
such right of resumption, or a health or physical condition of any other
person who is covered by the contract unless:
(1) the condition arose during the period of active duty and the
condition has been determined by the secretary of veterans affairs to be
a condition incurred in the line of duty; or
(2) a waiting period was imposed and had not been completed prior to
the period of suspension; in no event, however, shall the sum of the
waiting periods imposed prior to and subsequent to the period of
suspension exceed the length of the waiting period originally imposed.
(j) To be entitled to the right defined in subsection (i) of this
section a person must be a member of a reserve component of the armed
forces of the United States, including the National Guard, who either:
(1) voluntarily or involuntarily enters upon active duty (other than
for the purpose of determining his or her physical fitness and other
than for training), or
(2) has his or her active duty voluntarily or involuntarily extended
during a period when the president is authorized to order units of the
ready reserve or members of a reserve component to active duty, provided
that such additional active duty is at the request and for the
convenience of the federal government, and
(3) serves no more than four years of active duty.
(k) A contract for which the premiums are paid by a remitting agent of
a group issued by a hospital service, health service or medical expense
indemnity corporation shall provide that if all or any portion of the
insurance on an employee or member insured under the contract ceases
because of termination of employment or membership in the class or
classes eligible for coverage under the contract, such employee or
member shall be entitled without evidence of insurability upon
application to continue his or her insurance for himself or herself and
his or her eligible dependents, subject to all of the group remittance
contract's terms and conditions applicable to those forms of benefits
and to the following conditions:
(1) Continuation shall not be available for: (A) any person who is
covered, becomes covered or could be covered by title XVIII of the
United States Social Security Act (Medicare) as amended or superseded;
or (B) an employee, member or dependent who is covered, becomes covered
or could become covered as an employee, member or dependent by any other
insured or uninsured arrangement which provides hospital, surgical or
medical coverage for individuals in a group which does not contain any
exclusion or limitation with respect to any pre-existing condition of
such employee, member or dependent, except the group insurance or group
remittance contract conversion option of this section shall not be
considered as such an arrangement under which an employee, member or
dependent could become covered.
(2) (A) An employee or member who wishes continuation of coverage must
request such continuation in writing within the sixty day period
following the later of: (i) the date of such termination; or (ii) the
date the employee is given notice of the right of continuation by either
his employer or the group remitting agent.
(B) An employee or member who wishes continuation of coverage under
subparagraph (D) of paragraph four of this subsection must give notice
to the employer or group remitting agent within sixty days of the
determination under title II or title XVI of the United States Social
Security Act that such employee or member was disabled at the time of
termination of employment or membership or at any time during the first
sixty days of continuation of coverage.
(3) An employee or member electing continuation must pay to the group
remitting agent or his employer, but not more frequently than on a
monthly basis in advance, the amount of the required premium payment,
but not more than one hundred two percent of the group rate for the
benefits being continued under the group remittance contract on the due
date of each payment. The employee's or member's written election of
continuation, together with the first premium payment required to
establish premium payment on a monthly basis in advance, must be given
to the group remitting agent or employer within sixty days of the date
the employee's or member's benefits would otherwise terminate.
(4) Subject to paragraph one of this subsection, continuation of
benefits under the group remittance contract for any person shall
terminate at the first to occur of the following:
(A) The date thirty-six months after the date the employee's or
member's benefits under the contract would otherwise have terminated
because of termination of employment or membership; or
(B) The end of the period for which premium payments were made, if the
employee or member fails to make timely payment of a required premium
payment; or
(C) In the case of an eligible dependent of an employee or member, the
date thirty-six months after the date such person's benefits under the
contract would otherwise have terminated by reason of:
(i) the death of the employee or member;
(ii) the divorce or legal separation of the employee or member from
his or her spouse;
(iii) the employee or member becoming entitled to benefits under title
XVIII of the United States Social Security Act (Medicare); or
(iv) a dependent child ceasing to be a dependent child under the
generally applicable requirements of the contract; or
(D) The date on which the group remittance contract with that
remitting agent is terminated or, in the case of an employee, the date
his employer terminates participation under the group remittance
contract. However, if this clause applies and the coverage ceasing by
reason of such termination is replaced by similar coverage under another
group or group remittance contract, the following shall apply:
(i) The employee or member shall have the right to become covered
under that other group or group remittance contract, for the balance of
the period that he would have remained covered under the prior group
remittance contract in accordance with this subparagraph had a
termination described in this subparagraph not occurred, and
(ii) The minimum level of benefits to be provided by the other group
or group remittance contract shall be the applicable level of benefits
of the prior group remittance contract reduced by any benefits payable
under that prior group remittance contract, and
(iii) The prior group remittance contract shall continue to provide
benefits to the extent of its accrued liabilities and extension of
benefits as if the replacement had not occurred.
(5)(A) Special enrollment period. An individual who does not have an
election of continuation coverage as described in this subsection in
effect on the effective date of the American Recovery and Reinvestment
act of 2009, but who would be an assistance eligible individual under
Title III of such act if such election were in effect, may elect
continuation coverage pursuant to this subsection. Such election must be
made no later than sixty days after the date the administrator of the
group health plan (or other entity involved) provides the notice
required by section 3001(a)(7) of the American Recovery and Reinvestment
act of 2009. The administrator of the group health plan (or other entity
involved) shall provide such individuals with additional notice of the
right to elect coverage pursuant to this paragraph within sixty days of
the date of enactment of the American Recovery and Reinvestment act of
2009.
(B) Continuation coverage elected pursuant to subparagraph (A) of this
paragraph shall commence with the first period of coverage beginning on
or after the date of the enactment of the American Recovery and
Reinvestment act of 2009 and shall not extend beyond the period of
continuation coverage that would have been required if the coverage had
instead been elected pursuant to paragraph two of this subsection.
(C) With respect to an individual who elects continuation coverage
pursuant to subparagraph (A) of this paragraph, the period beginning on
the date of the qualifying event and ending on the date of the first
period of coverage on or after the enactment of the American Recovery
and Reinvestment act of 2009 shall be disregarded for purposes of
determining the sixty-three day period referred to in section four
thousand three hundred eighteen of this article.
(6) A contract for which premiums are paid by a remitting agent for a
group issued by a hospital service, health service or medical expense
indemnity corporation shall offer an employee or member who has
exhausted continuation coverage pursuant to Chapter 18 of the Employee
Retirement Income Security Act, 29 U.S.C. § 1161 et seq. or Chapter 6A
of the Public Health Service Act, 42 U.S.C. § 300 bb - 1 et seq. the
opportunity to continue coverage for up to thirty-six months from the
date the employee's or member's continuation coverage began if the
employee or member is entitled to less than thirty-six months of
continuation benefits.
(7) For purposes of this subsection, the term "dependent" shall
include a child as described in subsection (d) of this section.
(l) A corporation shall not offer individual hospital, medical, or
surgical expense insurance contracts unless the contracts meet the
requirements of subsection (b) of section four thousand three hundred
twenty-eight of this article. Such contracts that are offered within the
health benefit exchange established by this state also shall meet any
requirements established by the health benefit exchange. To the extent
that a holder of a special purpose certificate of authority issued
pursuant to section four thousand four hundred three-a of the public
health law offers individual hospital, medical, or surgical expense
insurance contracts, the contracts shall meet the requirements of
subsection (b) of section four thousand three hundred twenty-eight of
this article.
(m) (1) As used in this subsection, "child" means an unmarried child
through age twenty-nine of an employee or member insured under a group
remittance contract of hospital, medical or surgical expense insurance,
regardless of financial dependence, who is not insured by or eligible
for coverage under any employer health benefit plan as an employee or
member, whether insured or self-insured, and who lives, works or resides
in New York state or the service area of the corporation and who is not
covered under title XVIII of the United States Social Security Act
(Medicare).
(2) In addition to the conversion privilege afforded by subsection (e)
of this section and the continuation privilege afforded by subsections
(e) and (k) of this section, a hospital service, health service or
medical expense corporation or health maintenance organization that
provides hospital, medical or surgical expense insurance coverage for
which the premiums are paid by the remitting agent of a group that
provides coverage of a child that terminates at a specified age shall,
upon application of the employee, member or child, as set forth in
subparagraph (B) of this paragraph, provide coverage to the child after
that specified age and through age twenty-nine without evidence of
insurability, subject to all of the terms and conditions of the group
remittance contract and the following:
(A) An employer shall not be required to pay all or part of the cost
of coverage for a child provided pursuant to this subsection;
(B) An employee, member or child who wishes to elect continuation of
coverage pursuant to this subsection shall request the continuation in
writing:
(i) within sixty days following the date coverage would otherwise
terminate due to reaching the specified age set forth in the group
contract;
(ii) within sixty days after meeting the requirements for child status
set forth in paragraph one of this subsection when coverage for the
child previously terminated; or
(iii) during an annual thirty-day open enrollment period as described
in the contract.
(C) An employee, member or child electing continuation as described in
this subsection shall pay to the group remitting agent or employer, but
not more frequently than on a monthly basis in advance, the amount of
the required premium payment on the due date of each payment. The
written election of continuation, together with the first premium
payment required to establish premium payment on a monthly basis in
advance, shall be given to the group remitting agent or employer within
the time periods set forth in subparagraph (B) of this paragraph. Any
premium received within the thirty-day period after the due date shall
be considered timely;
(D) For any child electing coverage within sixty days of the date the
child would otherwise lose coverage due to reaching a specified age, the
effective date of the continuation coverage shall be the date coverage
would have otherwise terminated. For any child electing to resume
coverage during an annual open enrollment period, the effective date of
the continuation coverage shall be prospective no later than thirty days
after the election and payment of first premium;
(E) Coverage for a child pursuant to this subsection shall consist of
coverage that is identical to the coverage provided to the employee or
member parent. If coverage is modified under the contract for any group
of similarly situated employees or members, then the coverage shall also
be modified in the same manner for any child;
(F) Coverage shall terminate on the first to occur of the following:
(i) the date the child no longer meets the requirements of paragraph
one of this subsection;
(ii) the end of the period for which premium payments were made, if
there is a failure to make payment of a required premium payment within
the period of grace described in subparagraph (C) of this paragraph; or
(iii) the date on which the group remittance contract is terminated
and not replaced by coverage under another group or group remittance
contract; and
(G) The corporation or health maintenance organization shall provide
written notification of the continuation privilege described in this
subsection and the time period in which to request continuation to the
employee or member:
(i) in each certificate of coverage; and
(ii) at least sixty days prior to termination at the specified age as
provided in the contract.
(3)(A) Corporations and health maintenance organizations shall submit
such reports as may be requested by the superintendent to evaluate the
effectiveness of coverage pursuant to this subsection including, but not
limited to, quarterly enrollment reports.
(B) The superintendent may promulgate regulations to ensure the
orderly implementation and operation of the continuation coverage
provided pursuant to this subsection, including premium rate
adjustments.
provisions of this article may issue a contract to an individual the
premiums for which may be paid to the corporation directly by the
individual or by a remitting agent for the group to which the individual
belongs. If the premiums for a contract issued pursuant to this section
are paid to the corporation by a remitting agent, such contract shall be
subject to subsections (k) and (l) of section four thousand two hundred
thirty-five of this chapter, and for the purposes of these subsections,
the remitting agent shall be treated as the policyholder.
(b)(1) Any such contract shall be for a period not in excess of twelve
months, but no contract shall be made providing for the inception of
benefits at a date later than one year from the date of the contract.
(2) Any such contract shall provide that it will be automatically
renewed from year to year unless there shall have been one month's prior
written notice of termination by the subscriber.
(3) No corporation shall refuse to renew any such contract because of
the physical or mental condition or the health of any person covered
thereunder. The provisions of this subsection shall in no way diminish
the rights of individuals pursuant to section four thousand three
hundred seventeen of this article.
(c) Any such contract may be terminated in the following manner:
(1) At the option of the individual to whom the contract is issued,
upon not less than one month's prior written notice.
(2) At the option of the corporation, for one or more of the following
reasons:
(A) The individual has failed to pay premiums or contributions in
accordance with the terms of the contract or the corporation has not
received timely premium payments.
(B) The individual has performed an act or practice that constitutes
fraud or made an intentional misrepresentation of material fact under
the terms of the contract, upon not less than one month's prior written
notice.
(C) (i) Discontinuance of a class of contract upon not less than
ninety days' prior written notice. In exercising the option to
discontinue coverage pursuant to this item, the corporation must act
uniformly without regard to any health status-related factor of enrolled
individuals or individuals who may become eligible for such coverage and
must offer to subscribers or group remitting agents, as may be
appropriate, the option to purchase all other individual health
insurance coverage currently being offered by the corporation to
applicants in that market. Provided, however, the superintendent may,
after giving due consideration to the public interest, approve a request
made by a corporation for the corporation to satisfy the requirements of
this item through the offering of contracts at each level of coverage as
defined in subsection (b) of section four thousand three hundred six-h
of this article that contains the essential health benefits package
described in paragraph three of subsection (e) of section four thousand
three hundred six-h of this article by another corporation, insurer or
health maintenance organization within the corporation's same holding
company system, as defined in article fifteen of this chapter.
(ii) Discontinuance of all hospital, surgical or medical expense
coverage in the individual direct payment market in this state upon
written notice to the superintendent and to each subscriber not less
than one hundred eighty days prior to the date of the expiration of such
coverage. In the event of such a withdrawal from the individual direct
payment market, the corporation must also provide the superintendent
with a written plan to minimize potential disruption in the marketplace
occasioned by such withdrawal. In addition, the corporation may not
provide for the issuance of any hospital, surgical or medical expense
coverage in the individual direct payment market in this state during
the five-year period beginning on the date of the discontinuance of the
last health insurance coverage not so renewed.
(iii) Discontinuance of all individual hospital, surgical or medical
expense insurance contracts for which the premiums are paid by a
remitting agent of a group, in the small group market, or the large
group market, or both markets, in this state, in conjunction with a
withdrawal from the small group market, or the large group market, or
both markets, in this state. Withdrawal from the small group market, or
the large group market, or both markets, shall be governed by the
requirements of subparagraphs (E) and (F) of paragraph three of
subsection (j) of section four thousand three hundred five of this
article. For purposes of this item, "withdrawal" from a market means
that no coverage is offered or maintained in such market under contracts
issued pursuant to this section or contracts issued pursuant to section
four thousand three hundred five of this article.
(D) In the case of a corporation that offers health insurance in the
market through a network plan, the individual no longer resides, lives
or works in the service area (or in an area for which the corporation is
authorized to do business) but only if such coverage is terminated under
this paragraph uniformly without regard to any health status-related
factor of covered individuals. For the purposes of this subparagraph,
the term "network plan" means health insurance coverage of a corporation
organized under this article under which the financing and delivery of
health care (including items and services paid for as such care) are
provided, in whole or in part, through a defined set of providers under
contract either with the corporation or another entity that has
contracted with the corporation.
(E) In case of a contract for which the premiums are paid by a
remitting agent of a group, discontinuance of the individual's
membership in such group.
(F) Such other reasons as the superintendent may approve and
authorized by the Health Insurance Portability and Accountability Act of
1996, Public Law 104-191, and any later amendments or successor
provisions, or by any federal regulations or rules that implement the
provisions of the Act, upon not less than one month's prior written
notice.
(3) Every notice of termination shall be in a form satisfactory to the
superintendent and shall include a statement of the conversion
privileges, if any, upon such termination.
(4) In the event of termination of a contract, the corporation shall
return the unearned portion of the premium.
(d) (1) (A) No contract issued pursuant to this section shall entitle
more than one person to benefits except that a contract issued and
marked as a "family contract" may provide that benefits will be
furnished to the contract holder, spouse, dependent child or children,
or other person chiefly dependent upon the contract holder provided
that:
(i) A "family contract" may provide coverage to any child or children
not over nineteen years of age, provided that an unmarried student at an
accredited institution of learning may be considered a dependent until
the child becomes twenty-three years of age, and provided also that the
coverage of any such "family contract" may include, at the option of the
corporation, any unmarried child until attaining age twenty-five.
However, a "family contract" of hospital, medical, surgical, or
prescription drug expense insurance that provides coverage for dependent
children shall provide such coverage to a married or unmarried child
until attainment of age twenty-six without regard to financial
dependence, residency with the contract holder, student status, or
employment.
(ii) The coverage of any such "family contract" shall include any
other unmarried child, regardless of age, who is incapable of
self-sustaining employment by reason of mental illness, developmental
disability, as defined in the mental hygiene law, or physical handicap
and who became so incapable prior to attainment of the age at which
coverage would otherwise terminate.
(B) In addition to the requirements of subparagraph (A) of this
paragraph, every corporation issuing a contract of hospital, medical or
surgical expense insurance that provides coverage for children must make
available and if requested by the contractholder, extend coverage under
the contract to an unmarried child through age twenty-nine, without
regard to financial dependence who is not insured by or eligible for
coverage under any employer health benefit plan as an employee or
member, whether insured or self-insured, and who lives, works or resides
in New York state or the service area of the corporation. Such coverage
shall be made available at the inception of all new contracts, and for
group remittance contracts at any anniversary date. Written notice of
the availability of such coverage shall be delivered to the
contractholder prior to the inception of such contract, and for group
remittance contracts annually thereafter.
(C) Notwithstanding any rule, regulation or law to the contrary, any
"family contract" shall provide that coverage of newborn infants,
including newly born infants adopted by the subscriber if such
subscriber takes physical custody of the infant upon such infant's
release from the hospital and files a petition pursuant to section one
hundred fifteen-c of the domestic relations law within thirty days of
birth; and provided further that no notice of revocation to the adoption
has been filed pursuant to section one hundred fifteen-b of the domestic
relations law and consent to the adoption has not been revoked, shall be
effective from the moment of birth for injury or sickness including the
necessary care and treatment of medically diagnosed congenital defects
and birth abnormalities including premature birth, except that in cases
of adoption, coverage of the initial hospital stay shall not be required
where a birth parent has insurance coverage available for the infant's
care. This provision regarding coverage of newborn infants shall not
apply to two person coverage. In the case of individual or two person
coverages the corporation must also permit the person to whom the
contract is issued to elect such coverage of newborn infants from the
moment of birth. If notification and/or payment of an additional premium
or contribution is required to make coverage effective for a newborn
infant, the coverage may provide that such notice and/or payment be made
within no less than thirty days of the day of birth to make coverage
effective from the moment of birth. This election shall not be required
in the case of student insurance or where the group remitting agent's
plan does not provide coverage for children.
(2) Every "family contract" under which coverage of a dependent spouse
or contract holder would terminate upon such spouse or contract holder
attaining the age prescribed in subchapter XVIII of the Social Security
Act, 42 U.S.C. § 1395 et seq ("Medicare"), as the age of first
eligibility for the benefits provided by such law shall not so
terminate, if such dependent spouse is not eligible for all of such
benefits, for as long as the contract remains in force and such
dependent spouse remains ineligible to receive any of such "medicare"
benefits, provided proof of such ineligibility is submitted to the
corporation within thirty-one days of the date notice of termination of
coverage is mailed by the corporation to the last known address of the
such spouse or contract holder.
(3) Coverage of an unmarried dependent child who is incapable of
self-sustaining employment by reason of mental illness, developmental
disability, as defined in the mental hygiene law, or physical handicap
and who became so incapable prior to attainment of the age at which
coverage would otherwise terminate and who is chiefly dependent upon the
contract holder for support and maintenance, shall not terminate while
the contract remains in force and the child remains in such condition,
if the contract holder has within thirty-one days of such child's
attainment of the limiting age submitted proof of such child's
incapacity as described herein.
(e) (1) (A) If any such contract is terminated in accordance with the
provisions of paragraph one of subsection (c) of this section, or any
such contract is terminated because of a default by the remitting agent
in the payment of premiums not cured within the grace period and the
remitting agent has not replaced the contract with similar and
continuous coverage for the same group whether insured or self-insured,
or any such contract is terminated in accordance with the provisions of
subparagraph (E) of paragraph two of subsection (c) of this section, or
if an individual other than the contract holder is no longer covered
under a "family contract" because the individual is no longer within the
definition set forth in the contract, or a spouse is no longer covered
under the contract because of divorce from the contract holder or
annulment of the marriage, or any such contract is terminated because of
the death of the contract holder, then such individual, former spouse,
or in the case of the death of the contract holder the surviving spouse
or other dependents of the deceased contract holder covered under the
contract, as the case may be, shall be entitled to convert, without
evidence of insurability, upon application therefor and the making of
the first payment thereunder within sixty days after the date of
termination of such contract, to a contract that contains the essential
health benefits package described in paragraph three of subsection (e)
of section four thousand three hundred six-h of this article.
(B) The corporation shall offer one contract at each level of coverage
as defined in subsection (b) of section four thousand three hundred
six-h of this article. The individual may choose any such contract
offered by the corporation. Provided, however, the superintendent may,
after giving due consideration to the public interest, approve a request
made by a corporation for the corporation to satisfy the requirements of
this paragraph through the offering of contracts that comply with this
paragraph by another corporation, insurer or health maintenance
organization within the corporation's same holding company system, as
defined in article fifteen of this chapter.
(C) The effective date of the coverage provided by the converted
direct payment contract shall be the date of the termination of coverage
under the contract from which conversion was made.
(2) The corporation shall not be required to issue any such converted
individual direct payment contract if its issuance would result in
overinsurance or duplication of benefits according to standards on file
with the superintendent and approved by the superintendent with regard
to such contracts.
(3) In addition to the right of conversion herein, the employee or
member insured under a contract for which the premiums are paid by a
remitting agent of a group shall at his option, as an alternative to
conversion, be entitled to have his coverage continued under the group
remittance contract in accordance with the conditions and limitations
contained in subsection (k) of this section, and have issued at the end
of the period of continuation an individual direct payment conversion
contract subject to the terms of this subsection. The effective date for
the conversion contract shall be the day following the termination of
insurance under the group remittance contract, or if there is a
continuation of coverage, on the day following the end of the period of
continuation.
(4) For purposes of this subsection, the term "dependent" shall
include a child as described in subsection (d) of this section.
(f) No such corporation shall require as a condition for renewal or
for failure to cancel any individual contract any rider, endorsement or
other attachment which shall limit the nature or extent of the benefits
thereunder, except that a corporation may at any time upon at least
thirty days' prior written notice amend such contract to provide a
different level of benefits thereunder if approved by the superintendent
on finding, upon application by the corporation at least four months
before the proposed effective date, that such level would exceed, in the
aggregate, the level of benefits theretofore provided and would be in
the best interests of the corporation and the persons covered under such
contracts.
(g) The provisions of this section with respect to limitations on the
termination of an individual contract shall not apply to a contract or
an endorsement or rider thereto which is issued by a corporation subject
to the provisions of this article pursuant to a plan providing for
experimentation in new forms of benefits in the field of health
insurance protection, which plan shall be submitted in writing to the
superintendent. The superintendent shall approve such plan if he finds
that the benefits are of the type heretofore described and that the
issuance of such contract, endorsement or rider is in the public
interest. Approval of such contract, rider or endorsement shall be
subject to any conditions which may be prescribed by the superintendent,
including, but not limited to, the maximum period during which the
exemption from the provisions of this section with respect to
termination shall continue. The superintendent may, for good cause
shown, extend such period of exemption. Any termination of such
contract, rider or endorsement during the period of exemption, other
than for non-payment of premium and fraud in applying for the contract,
shall be subject to the approval of the superintendent. Upon termination
of such contract, or termination of a rider or endorsement providing
experimental benefits, as aforesaid, the contract holder thereunder who
has at the time of such termination been covered continuously
immediately preceding such termination for a period of two years or more
under one or more contracts of the corporation shall be entitled to have
issued to him by the corporation, without evidence of insurability, upon
application therefor and the making of the first payment thereunder
within thirty-one days after the date of termination, an individual
direct payment contract of the type and class which the superintendent
shall determine provides benefits most nearly comparable to those
currently provided other individuals. If the corporation does not
terminate such contract or a rider or endorsement thereto providing
experimental benefits as aforesaid during the period of exemption, or
any extended period provided herein, such contract shall thereafter be
subject to the provisions of this section with respect to termination as
of the original effective date of such contract.
(h) Any contract, other than one issued in fulfillment of the
continuing care responsibilities of an operator of a continuing care
retirement community in accordance with article forty-six of the public
health law, made available because of residence in a particular
facility, housing development, or community shall contain the following
notice in twelve point type in bold face on the first page:
"NOTICE - THIS CONTRACT DOES NOT MEET THE REQUIREMENTS OF A CONTINUING
CARE RETIREMENT CONTRACT. AVAILABILITY OF THIS COVERAGE WILL NOT QUALIFY
A RESIDENTIAL FACILITY AS A CONTINUING CARE RETIREMENT COMMUNITY."
(i) Any persons covered by the contract who are also members of a
reserve component of the armed forces of the United States, including
the National Guard, shall be entitled, upon written request, to have
their coverage suspended during a period of active duty as described
herein. The contract shall provide that the insurer will refund any
unearned premiums for the period of such suspension. Persons covered by
the contract shall be entitled to resumption of coverage, upon written
application and payment of the required premium within sixty days after
the date of termination of the period of active duty, with no
limitations or conditions imposed as a result of such period of active
duty except as set forth in paragraphs one and two herein. Coverage
shall be retroactive to the date of termination of the period of active
duty. Such right of resumption provided for herein shall be in addition
to other existing rights granted pursuant to state and federal laws and
regulations and shall not be deemed to qualify or limit such rights in
any way. No exclusion or waiting period may be imposed in connection
with coverage of a health or physical condition of a person entitled to
such right of resumption, or a health or physical condition of any other
person who is covered by the contract unless:
(1) the condition arose during the period of active duty and the
condition has been determined by the secretary of veterans affairs to be
a condition incurred in the line of duty; or
(2) a waiting period was imposed and had not been completed prior to
the period of suspension; in no event, however, shall the sum of the
waiting periods imposed prior to and subsequent to the period of
suspension exceed the length of the waiting period originally imposed.
(j) To be entitled to the right defined in subsection (i) of this
section a person must be a member of a reserve component of the armed
forces of the United States, including the National Guard, who either:
(1) voluntarily or involuntarily enters upon active duty (other than
for the purpose of determining his or her physical fitness and other
than for training), or
(2) has his or her active duty voluntarily or involuntarily extended
during a period when the president is authorized to order units of the
ready reserve or members of a reserve component to active duty, provided
that such additional active duty is at the request and for the
convenience of the federal government, and
(3) serves no more than four years of active duty.
(k) A contract for which the premiums are paid by a remitting agent of
a group issued by a hospital service, health service or medical expense
indemnity corporation shall provide that if all or any portion of the
insurance on an employee or member insured under the contract ceases
because of termination of employment or membership in the class or
classes eligible for coverage under the contract, such employee or
member shall be entitled without evidence of insurability upon
application to continue his or her insurance for himself or herself and
his or her eligible dependents, subject to all of the group remittance
contract's terms and conditions applicable to those forms of benefits
and to the following conditions:
(1) Continuation shall not be available for: (A) any person who is
covered, becomes covered or could be covered by title XVIII of the
United States Social Security Act (Medicare) as amended or superseded;
or (B) an employee, member or dependent who is covered, becomes covered
or could become covered as an employee, member or dependent by any other
insured or uninsured arrangement which provides hospital, surgical or
medical coverage for individuals in a group which does not contain any
exclusion or limitation with respect to any pre-existing condition of
such employee, member or dependent, except the group insurance or group
remittance contract conversion option of this section shall not be
considered as such an arrangement under which an employee, member or
dependent could become covered.
(2) (A) An employee or member who wishes continuation of coverage must
request such continuation in writing within the sixty day period
following the later of: (i) the date of such termination; or (ii) the
date the employee is given notice of the right of continuation by either
his employer or the group remitting agent.
(B) An employee or member who wishes continuation of coverage under
subparagraph (D) of paragraph four of this subsection must give notice
to the employer or group remitting agent within sixty days of the
determination under title II or title XVI of the United States Social
Security Act that such employee or member was disabled at the time of
termination of employment or membership or at any time during the first
sixty days of continuation of coverage.
(3) An employee or member electing continuation must pay to the group
remitting agent or his employer, but not more frequently than on a
monthly basis in advance, the amount of the required premium payment,
but not more than one hundred two percent of the group rate for the
benefits being continued under the group remittance contract on the due
date of each payment. The employee's or member's written election of
continuation, together with the first premium payment required to
establish premium payment on a monthly basis in advance, must be given
to the group remitting agent or employer within sixty days of the date
the employee's or member's benefits would otherwise terminate.
(4) Subject to paragraph one of this subsection, continuation of
benefits under the group remittance contract for any person shall
terminate at the first to occur of the following:
(A) The date thirty-six months after the date the employee's or
member's benefits under the contract would otherwise have terminated
because of termination of employment or membership; or
(B) The end of the period for which premium payments were made, if the
employee or member fails to make timely payment of a required premium
payment; or
(C) In the case of an eligible dependent of an employee or member, the
date thirty-six months after the date such person's benefits under the
contract would otherwise have terminated by reason of:
(i) the death of the employee or member;
(ii) the divorce or legal separation of the employee or member from
his or her spouse;
(iii) the employee or member becoming entitled to benefits under title
XVIII of the United States Social Security Act (Medicare); or
(iv) a dependent child ceasing to be a dependent child under the
generally applicable requirements of the contract; or
(D) The date on which the group remittance contract with that
remitting agent is terminated or, in the case of an employee, the date
his employer terminates participation under the group remittance
contract. However, if this clause applies and the coverage ceasing by
reason of such termination is replaced by similar coverage under another
group or group remittance contract, the following shall apply:
(i) The employee or member shall have the right to become covered
under that other group or group remittance contract, for the balance of
the period that he would have remained covered under the prior group
remittance contract in accordance with this subparagraph had a
termination described in this subparagraph not occurred, and
(ii) The minimum level of benefits to be provided by the other group
or group remittance contract shall be the applicable level of benefits
of the prior group remittance contract reduced by any benefits payable
under that prior group remittance contract, and
(iii) The prior group remittance contract shall continue to provide
benefits to the extent of its accrued liabilities and extension of
benefits as if the replacement had not occurred.
(5)(A) Special enrollment period. An individual who does not have an
election of continuation coverage as described in this subsection in
effect on the effective date of the American Recovery and Reinvestment
act of 2009, but who would be an assistance eligible individual under
Title III of such act if such election were in effect, may elect
continuation coverage pursuant to this subsection. Such election must be
made no later than sixty days after the date the administrator of the
group health plan (or other entity involved) provides the notice
required by section 3001(a)(7) of the American Recovery and Reinvestment
act of 2009. The administrator of the group health plan (or other entity
involved) shall provide such individuals with additional notice of the
right to elect coverage pursuant to this paragraph within sixty days of
the date of enactment of the American Recovery and Reinvestment act of
2009.
(B) Continuation coverage elected pursuant to subparagraph (A) of this
paragraph shall commence with the first period of coverage beginning on
or after the date of the enactment of the American Recovery and
Reinvestment act of 2009 and shall not extend beyond the period of
continuation coverage that would have been required if the coverage had
instead been elected pursuant to paragraph two of this subsection.
(C) With respect to an individual who elects continuation coverage
pursuant to subparagraph (A) of this paragraph, the period beginning on
the date of the qualifying event and ending on the date of the first
period of coverage on or after the enactment of the American Recovery
and Reinvestment act of 2009 shall be disregarded for purposes of
determining the sixty-three day period referred to in section four
thousand three hundred eighteen of this article.
(6) A contract for which premiums are paid by a remitting agent for a
group issued by a hospital service, health service or medical expense
indemnity corporation shall offer an employee or member who has
exhausted continuation coverage pursuant to Chapter 18 of the Employee
Retirement Income Security Act, 29 U.S.C. § 1161 et seq. or Chapter 6A
of the Public Health Service Act, 42 U.S.C. § 300 bb - 1 et seq. the
opportunity to continue coverage for up to thirty-six months from the
date the employee's or member's continuation coverage began if the
employee or member is entitled to less than thirty-six months of
continuation benefits.
(7) For purposes of this subsection, the term "dependent" shall
include a child as described in subsection (d) of this section.
(l) A corporation shall not offer individual hospital, medical, or
surgical expense insurance contracts unless the contracts meet the
requirements of subsection (b) of section four thousand three hundred
twenty-eight of this article. Such contracts that are offered within the
health benefit exchange established by this state also shall meet any
requirements established by the health benefit exchange. To the extent
that a holder of a special purpose certificate of authority issued
pursuant to section four thousand four hundred three-a of the public
health law offers individual hospital, medical, or surgical expense
insurance contracts, the contracts shall meet the requirements of
subsection (b) of section four thousand three hundred twenty-eight of
this article.
(m) (1) As used in this subsection, "child" means an unmarried child
through age twenty-nine of an employee or member insured under a group
remittance contract of hospital, medical or surgical expense insurance,
regardless of financial dependence, who is not insured by or eligible
for coverage under any employer health benefit plan as an employee or
member, whether insured or self-insured, and who lives, works or resides
in New York state or the service area of the corporation and who is not
covered under title XVIII of the United States Social Security Act
(Medicare).
(2) In addition to the conversion privilege afforded by subsection (e)
of this section and the continuation privilege afforded by subsections
(e) and (k) of this section, a hospital service, health service or
medical expense corporation or health maintenance organization that
provides hospital, medical or surgical expense insurance coverage for
which the premiums are paid by the remitting agent of a group that
provides coverage of a child that terminates at a specified age shall,
upon application of the employee, member or child, as set forth in
subparagraph (B) of this paragraph, provide coverage to the child after
that specified age and through age twenty-nine without evidence of
insurability, subject to all of the terms and conditions of the group
remittance contract and the following:
(A) An employer shall not be required to pay all or part of the cost
of coverage for a child provided pursuant to this subsection;
(B) An employee, member or child who wishes to elect continuation of
coverage pursuant to this subsection shall request the continuation in
writing:
(i) within sixty days following the date coverage would otherwise
terminate due to reaching the specified age set forth in the group
contract;
(ii) within sixty days after meeting the requirements for child status
set forth in paragraph one of this subsection when coverage for the
child previously terminated; or
(iii) during an annual thirty-day open enrollment period as described
in the contract.
(C) An employee, member or child electing continuation as described in
this subsection shall pay to the group remitting agent or employer, but
not more frequently than on a monthly basis in advance, the amount of
the required premium payment on the due date of each payment. The
written election of continuation, together with the first premium
payment required to establish premium payment on a monthly basis in
advance, shall be given to the group remitting agent or employer within
the time periods set forth in subparagraph (B) of this paragraph. Any
premium received within the thirty-day period after the due date shall
be considered timely;
(D) For any child electing coverage within sixty days of the date the
child would otherwise lose coverage due to reaching a specified age, the
effective date of the continuation coverage shall be the date coverage
would have otherwise terminated. For any child electing to resume
coverage during an annual open enrollment period, the effective date of
the continuation coverage shall be prospective no later than thirty days
after the election and payment of first premium;
(E) Coverage for a child pursuant to this subsection shall consist of
coverage that is identical to the coverage provided to the employee or
member parent. If coverage is modified under the contract for any group
of similarly situated employees or members, then the coverage shall also
be modified in the same manner for any child;
(F) Coverage shall terminate on the first to occur of the following:
(i) the date the child no longer meets the requirements of paragraph
one of this subsection;
(ii) the end of the period for which premium payments were made, if
there is a failure to make payment of a required premium payment within
the period of grace described in subparagraph (C) of this paragraph; or
(iii) the date on which the group remittance contract is terminated
and not replaced by coverage under another group or group remittance
contract; and
(G) The corporation or health maintenance organization shall provide
written notification of the continuation privilege described in this
subsection and the time period in which to request continuation to the
employee or member:
(i) in each certificate of coverage; and
(ii) at least sixty days prior to termination at the specified age as
provided in the contract.
(3)(A) Corporations and health maintenance organizations shall submit
such reports as may be requested by the superintendent to evaluate the
effectiveness of coverage pursuant to this subsection including, but not
limited to, quarterly enrollment reports.
(B) The superintendent may promulgate regulations to ensure the
orderly implementation and operation of the continuation coverage
provided pursuant to this subsection, including premium rate
adjustments.