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Insurance policies or contracts that provide hospital, surgical, or medical care on an expense-incurred basis are subject to the requirements set forth in Insurance Law Articles 32, 43 and 49. Specifically, these State laws set forth minimum standards and consumer protections applicable to comprehensive hospital, surgical, and medical insurance coverage. Furthermore, New York codified many of the protections of the Affordable Care Act (“ACA”) into State law.2 For example, the prohibition on annual and lifetime limits on essential health benefits was adopted in State law.3 These State laws are independent of federal law and apply to an individual, group or blanket policy or contract of hospital, surgical, or medical expense insurance.
In determining whether a health insurance policy or contract pays on an expense-incurred basis, issuers must use the standards set forth in 11 NYCRR 52.5 and 52.6. Health insurance policies or contracts that exceed the benefit amounts in §§ 52.5 and 52.6 are deemed expense-incurred insurance in accordance with 11 NYCRR 360.2(c) and (f). Expense-incurred hospital, surgical, or medical insurance is subject to all requirements for comprehensive health insurance coverage under New York law including mandated benefits, minimum loss ratios, community rating for individual and small groups, prohibitions on annual and lifetime limits, and prohibitions on pre-existing condition limitations. The requirements under New York law are independent of federal law. While a limited benefits health insurance policy or contract may meet the definitions of excepted benefits in federal rules,4 no such excepted benefit status is recognized under New York law.
In addition, Insurance Law § 3103(a) provides that “…any policy of insurance or contract of annuity delivered or issued for delivery in this state in violation of any of the provisions of this chapter shall be valid and binding upon the insurer issuing the same, but in all respects in which its provisions are in violation of the requirements or prohibitions of this chapter it shall be enforceable as if it conformed with such requirements or prohibitions.” Therefore, a limited benefits health insurance policy or contract that exceeds the benefit amounts contained within §§ 52.5 and 52.6 is deemed expense-incurred hospital, surgical, or medical insurance and subject to all requirements for comprehensive health insurance coverage under New York law.
Issuers are advised that although policy or contract approval may have predated the ACA and changes to New York law, once a change in State law becomes effective, policies or contracts must comply with such law or terminate upon renewal. Issuers should review their coverage offerings to determine whether they issue limited benefits health insurance policies or contracts. Issuers that have in-force limited benefits health insurance policies or contracts should notify the Department immediately. Issuers shall either discontinue the limited benefits health insurance policies or contracts upon renewal, or submit amendments to the policies and contracts to the Department for approval so that they meet all statutory and regulatory requirements for comprehensive health insurance coverage. The Department will continue to fully enforce State requirements vigorously to ensure that limited benefits health insurance policies or contracts are not offered within New York unless they comply with all statutory and regulatory requirements for comprehensive health insurance coverage. If an issuer has issued such a policy or contract in violation of New York law, the Department expects the issuer to provide coverage in accordance with New York law.
1 The Department is unaware of any in-force limited benefits health insurance policies or contracts that are guaranteed renewable. In the event issuers have in-force guaranteed renewable limited benefits health insurance policies or contracts, they should contact the Department.
2 See Chapter 217 of the Laws of 2011 and Chapter 56 of the Laws of 2013.
3 Insurance Law §§ 3217-f and 4306-e and 11 NYCRR 52.71.
4 See 45 CFR 146.145(b) and 45 CFR 148.220.
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In the text, there are two hundred and eighty-three "t"s.
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