New York State Law

Healthy New York covered services

1.

NY State Partnership for Long Term Care (3)

1. NY offers residents opportunity to participate in NY Partnership for LTC Program instead of using Medicaid 2. State LTC partnership programs collaboration between the states and private insurance companies 3. policy benefits pay for costs of LTC services first, before other payments made by any other source

Jurisdictional Licensing

1. ad can't imply the insurer is licensed in a jurisdiction in which it's not licensed 2. d can't imply the insurer, its financial condition, its payment of claims, or its policy forms and plans of insurance are approved, endorsed, or accredited by any government agency

Disparaging Comparisons and Statements (2)

1. ads can't make any type of unfair or incomplete comparisons of policies or their benefits (including comparisons of different policies from other insurers) 2. ads can't disparage or criticize competitors and/or their policies, services, business methods

Identity of Insurer (4)

1. ads must clearly identify name of the actual insurer and the form number(s) of applicable policies 2. ads can't use insurer's trade name, group designation, parent company name, service mark, slogan, or other symbol without also disclosing name of actual insurer 3. failure to do so will be construed as tending to mislead and deceive the public about true identity of insurer 4. no ad may use any combination of words, symbols, or physical materials that are similar enough in their content, phrasing, shape, color, ect. to confuse the public or mislead them to believe the ad is connected in some way with a government agency

Family Health Plus

1. adults between ages 19-94 who have income/resources too high to qualify for Medicaid 2. available to single adults, couples without kids, parents who are residents of NY, US citizens, or fall under many immigration categories 3. provides comprehensive coverage, including prevention, primary care, hospitalization, prescriptions, other services 4. minimal copays and health care services provided through participating managed care plans

Blanket insurance issued to (6)

1. any railroad, steamship, bus, or airplane carrier of passengers 2. employer covering a group of employees against exceptional hazards of employment 3. college, school, institution of learning 4. county, city, town, village, or fire district-including fire department, company, or corporation 5. association of persons with a common interest or calling - so long as the association has at least 50 members 6. group substantially similar to preceding groups, or any group that has the following characteristics 6a. members share a common business industry or financial social affinity or relationship 6b. premiums for coverage are reasonable based on benefits provided 6c. issuance of insurance is actuarially sound and isn't contrary to public interest

Most common types of medical plans (5)

1. basic hospital, medical, and surgical 2. major medical insurance (indemnity plans) 3. health maintenance organizations (HMOs) 4. preferred provider organizations (PPO) 5. point of service plans

any policy that insured more than one person against death or injury from accident is considered GROUP ACCIDENT INSURANCE EXCEPT (5)

1. blanket accident insurance 2. any individual policy 3. policy that provides indemnity benefits 4. family insurance 5. workers' compensation disability benefits

Insurance Broker License

1. brokers act on behalf of the client not the insurer. in exchange for commission (or any type of compensation), helps another person in any manner to 1a. solicit, negotiate, or sell insurance 1b. place insurance 1c. purchase insurance

Family Medical Leave Act (FMLA) Eligibility (5)

1. earned wages with covered employer for minimum of 6 months before filing an application for leave benefits 2. who was employed by the employer for at least 625 hours of service during previous 6 months 3. of a small employer that has elected to participate in the Program 4. who isn't an employee of the federal government 5. who is a self-employed individual

Family Medical Leave Act (FMLA)

1. enables an eligible employee of a covered employer to a family and medical leave insurance benefit for a total of 12 work weeks during any 12 month period for one or more of the following: 1a. birth of the employee's child 1b. placement of a child with the employee for adoption or foster care 1c. care for employee's child, parent, spouse, domestic partner, grandchild, grand parent, or sibling if person has serious health condition 1d. serious health condition that makes employee unable to perform functions of their position 1e. any qualifying, emergency arising out of the spouse, child, or parent of employee is on active duty and get called 1f. care for the employee's child, parent, spouse, grandchild, grandparent, sibling, of the employee who is a covered service member 2. during each 12 month period, each eligible employee is subject to waiting period of 5 workdays of leave (no more than 7 calendar days) 3. employee's leave benefit based on employee's annual income 3a. up to 20,000: an amount equal to 100% of employee's daily earnings 3b. 20,000-30,000: an amount equal to 75% of employee's daily earnings (100% if they make 20,000) 3c. 30,000-60,000: amount equal to 55% of employee's daily earnings (75% if they make 30k) 3d. 60,000-97,000: 40% of employee's daily earnings (55% for 60k)

if an insurer decides to discontinue offering all hospital, surgical, and major medical coverage in the individual market in NEW YORK, it must: (4)

1. give at least 180 days advance written notice to Superintendent 2. give at least 180 days written notice to each covered individual before coverage is discontinued 3. discontinue issuing and renewing all hospital, surgical, and major medical coverage in this state in the individual market 4. provide the Superintendent with a written plan to minimize potential disruption based on its withdrawal from the market

if an insurer decides to discontinue offering hospital, surgical, or major medical coverage in the individual market, it must: (4)

1. give at least 90 days advance written notice to Superintendent 2. give at least 90 days written notice to each covered individual before coverage is discontinued 3. offer each covered individual the option to purchase coverage in all other hospital, surgical, and major medical coverage plans currently being offered in individual market 4. act uniformly without regard to claims experience or any health status-related factor

Basic Hospital, Medical , and Surgical

1. in NY, basic hospital insurance must provide coverage with a deductible of no more than $500 for a period at least 60 days for any continuous hospital confinement per insured 2. daily room and board, including nursing care and special diets, for not less than the lesser of; 2a. 80% of semiprivate room charges 2b. 100% of semiprivate room charges for the first 20 days and 50% of the semiprivate room charges for the next 40 days 2c. $240/day (or $165/day for policies issued outside metropolitan area) 3. miscellaneous hospital services for inpatient hospital confinement, subject to following amounts; 3a. no less than 80% of incurred charges up to at least $5000 or 3b. 20 times the daily room and board rate, if specified in dollar amounts for at least: rooms and units and their equipment as well as items, casts, supplies, therapy, and other services and supplies

(Independent or Public) Adjuster

1. independent adjuster is any person or business, that in exchange for pay, acts on behalf of an insurer to investigate and adjust insurance claims arising under the insurer's policies. an employee of an independent adjuster who investigates and adjusts claims 2. independent adjuster performs duties required by the insurer that are incidental to its claims 3. public adjuster is any person that, in exchange for pay, acts on behalf of an insured to investigate and adjust insurance claims, this includes any person that advertises or solicits work as a public adjuster or that works for or on behalf of a public adjuster

Examples of personally identifiable information (6)

1. info a consumer provides on an insurance application 2. account balance info and payment history 3. fact that an individual is or has been one of the licensee's customers 4. any info about a consumer if it is disclosed in a manner that indicates individual is or has been the licensee's customer 5. any information the licensee collects through an internet "cookie" to extent the info constitutes personally identifiable information 6. info appearing on a consumer report

Noncancellable (4)

1. insurer may cancel the policy during the first 90 days after issue 2. written notice must be delivered to the insured or mailed by first class mail at the last address shown in insurer's records 3. insurer must issue a pro-rata cancellation refund of any premiums paid by the insured 4. cancellation can't be issued based on any claims that occurred before the policy's issue date

Relations of Earnings to Insurance

1. loss-of-time benefits can't exceed the greater of the insured's monthly earnings at time the disability commenced, or insured's average earning for the 2 years immediately preceding a disability 2. monthly benefit can't be reduced to less than $200

Nonpublic personal financial information

1. personally identifiable financial information and any customer list, description, or grouping that is derived using personally identifiable info that isn't publicly available 2. doesn't include health info

NY Eligible Groups

1. premiums may be paid by employer, employees, or both 1a. if employees pay any portion of the premium, policy must insure no less than 50% of eligible employees, or 1b. if group hospital, medical, major medical or similar insurance is being provided, if less than 50% of eligible employees are insured, then 50 or more employees must be insured 1c. for all other types of coverage being provided, plan must insure the lesser of 50% of eligible employees or 5 eligible employees

Healthy New York (2)

1. state program established for the purpose of making standardized health insurance available to individuals sole-proprietors, and small employers 2. effective Jan 1, 2014; Healthy New York stopped offering coverage to individuals and sole-proprietors and only offer coverage to small employers 3. Covered services 3a. inpatient hospital services (daily room and board, general nursing care, special diets, misc hospital services and supplies) 3b. outpatient hospital diagnostic and treatment services 3c. physician services (diagnostic and treatment services, consultant and referral, surgical services, anesthesia service, second surgical opinion, second opinion for cancer treatment) 3d. outpatient surgical facility charges 3e. preadmission testing 3f. maternity care 3g. adult preventive health service (mammography screening, cervical cytology screening, periodic physical examinations every 3 years, adult immunizations) 3h. preventive and primary health care services for dependent kids 3i. diabetes equipment, supplies, self-management education 3j. diagnostic x-ray and lab services 3k. emergency services 3l. radiologic, chemotherapy, hemodialysis 3m. prescription drugs obtained at a participating pharmacy 4. insurers aren't permitted to impose any pre-existing conditions exclusions or limitations on any plan that is not a grandfathered plan under the Patient Protection and Affordable Care Act 5. small group employers must pay at least 50% of employees' premiums and must offer coverage to all employees receiving annual of $30k or less 6. at least 1 employee must accept coverage 7. all contracts must be community rated and include specified rate tiers

Child Health Plus (4)

1. to be eligible for either Children's Medicaid or Child Health Plus, must be under 19 and residents of NY 2. whether child qualifies for Medicaid or Child Health Plus depends on family's gross income 3. not eligible for Medicaid --> Child Health Plus if they don't already have health insurance and aren't eligible for public employees' state health benefits plan 4. may have waiting period before enrolling in Child Health Plus if they were covered by employer-based health insurance within previous 6 months

NY LTC insurance policies assigned a 3 number identity (8)

A. 1.5/3/5 B. 3/6/50 C. 2/2/100 D. 4/4/100 E. all plans offer same services and provisions, but differ in amounts of some requirements F. first number refers to minimum number of years policy must pay for institutional care (skilled nursing facility, assisted living facility) G. second number refers to number of years policy must pay for home care or home health care H. third number refers to percentage of daily required minimum a policy must pay for home health care as opposed to institutional care

Required Disclosure Provisions

NY LTC policies must include following disclosures: 1. state or jurisdiction where contract was issued 2. disclosure statement not part of policy (separate document that briefly describes important policy features) 3. terms under which contract can be surrendered and returned to insurer for refund (free look period) 4. statement that long-term care insurance is NOT Medicare supplement insurance 5. statement that long-term care insurance policy is designed to provide insurance for no less than 24 consecutive months for each covered person: 5a. on expense incurred, indemnity, prepaid, or other basis 5b. for all levels of care in nursing home and home care benefits 5c. in the form of a fixed dollar indemnity benefit for covered long-term care expenses 5d. subject to specific conditions that must be specified in disclosure (limitations, waiting periods, coinsurance requirements)

LTC Eclusions (4)

NY can't exclude coverage unless: 1. preexisinting conditions 2. mental/nervous disorders other than Alzheimer's or organic brain disease 3. alcoholism/drug addiction 4. illness, treatment, medical condition arising out of: i. war/act of war ii. participation in felony, riot, insurrection iii. service in the armed forces iv. intentional self-inflicted injury v. flying a plane vi. treatment provided in government facility (unless required by law) or covered by a. medicare, or any other government program except medicaid b. any workers' comp, employer's liability, occupational disease law c. any mandatory motor vehicle no-fault law d. services provided by members of covered person's immediate family e. services for which no charge is normally made in absence of insurance

Affiliate

a company that controls, is controlled by, or is under common control with another company

Clear and Conspicuous

a notice is reasonably understandable and is designed to call attention to the info it contains and the importance of that info

Group Implications

ads can't state or imply that prospective insureds become members of a group to be covered under a group policy in order to enjoy special rates or underwriting privileges - unless the statement or implication is a fact

Personally identifiable financial information (3)

any information 1. a consumer provides to a licensee to obtain an insurance policy or services 2. about a consumer that results from an insurance transaction between a licensee and the consumer 3. a licensee obtains about a consumer in connection with the provision of insurance services or products to that consumer

Insurance Agent License

any person (individual or business entity) authorized or acknowledged by authorized insurer to act as its agent in the solicitation, negotiation, or sale of insurance

Nonpublic personal health information

health info that identifies an individual who is the subject of the information or provides reasonable basis to believe the information could be used to identify a specific individual

Renewability Clause (5)

insurers aren't permitted to non-renew any policy if one-third or more of total premium is allocated to hospital, surgical, or major medical benefits unless on or more of the following reasons apply 1. non-payment of premiums 2. fraud or material misrepresentation at time of applying for insurance or when applying for any policy benefits 3. discontinuance of a class of policies 4. discontinuance of all hospital, surgical, and medical expense coverage in individual market in NY 5. if an insurer offers individual polices through a network plan, an individual no longer resides, lives, or works in the service area of network

Home State

is the U.S. location where a person maintains a principal place of residence or business and the person is licenses to act as an insurance producer (all 50 states, D.C., any U.S. territory)

Sell/Sale

refer to exchange of insurance for money or its equivalent on behalf of a licensed insurer, fraternal benefit society, or HMO

Solicit/Solicitation

refers to attempt to sell insurance, or to ask or encourage a person to apply for insurance from a particular licensed insurance company, fraternal benefit society, or HMO

Negotiate/Negotiation

refers to process of one individual discussing with another a specific insurance contract and its major benefits, terms, and/or conditions

Employment Covered (10)

types of employment that are NOT covered: 1. persons in casual employment fewer than 45 days/calendar year 2. services performed as real estate broker or associate 3. maritime employment 4. service subject to the Federal Railroad and Unemployment Insurance Act 5. domestic workers in private homes who are employed for fewer than 40 hours per week by any one employer 6. professionals/ teachers working for religious, charitable, or educational institutions 7. independent contractors 8. licensed ministers, priests, rabbis, other religious personnel 9. farm laborers 10. executive officers of an incorporated religious, charitable, or educational institutions