Unit 25: NYS Law, Rules, & Regulations Pertinent To Accident & Health Insurance Only

Question 1

NY allows the opportunity to stay under a parent’s plan through what age?

Answer 1

•through age 29 to age 30

Question 2

What are some required provisions of accident & health insurance policies?

Answer 2

•reinstatement
•time limit on certain defenses
•grace period

Question 3

What is the purpose of the coordination of benefits provison?

Answer 3

•establish the order in which plans pay their claims
•provide for the orderly transfer of information needed to pay claims promptly
•reduce duplication of benefits by permitting a reduction of the benefits paid by a plan when the plan does not have to pay benefits first
•reduce delays in payment of claims

Question 4

What is the conversion privilege?

Answer 4

•must be included with group policies that provide hospital, surgical, or medical expense benefits
•option for conversion of coverage when insurance under the group policy has been terminated or for a surviving spouse & dependents of an insured who dies
•does NOT apply to specific disease or accidental injury-only policies
•employee or member may convert to an individual policy or, if elected by the insurer, a group policy, without evidence of insurability after applying in writing & paying the first premium within 60 days after the group coverage terminated
•conversion is not required if a converted policy would result in over-insurance or duplication of benefits
•converted policy must provide identical coverage for the dependents of an employee or member covered under the group policy

Question 5

What is a professional employer organization (PEO)?

Answer 5

•any person whose business is entering into professional employer agreements with clients
•considered the employer for purposes of sponsoring welfare benefit plans for its workforce employees

*NOT temporary help firms & employment agencies

Question 6

What is a professional employer agreement?

Answer 6

A written contract whereby:
•a PEO expressly agrees to co-employ all or a majority of the employees providing services for the client employer
•the contract is intended to be on-going rather than temporary in nature
•employer responsibilities for worksite employees, including those of hiring, firing & disciplining, are expressly allocated by & between the PEO & the client business
AND
•the PEO expressly assumes statutorily required rights & responsibilities

Question 7

What are conventional fully insured plans?

Answer 7

•traditional approach to finding & administering a group health plan
•insurer assumes the full amount of claims risks & premiums calculated annually

Question 8

What are partially self-funded plans?

Answer 8

•employer assumes the risk of covering some or all of the potential claims under the policy

Question 9

What is stop-loss coverage?

Answer 9

•large employer may utilize this approach when it covers the claims of the insureds up to a certain predetermined level of loss
•after that level has been reached, the insurer is responsible for covering the claims

Question 10

What is an administrative-services only (ASO) arrangement?

Answer 10

•employer will purchase the insurance expertise of a third-party administrator to perform administrative functions only, such as handling claims, maintaining records, & projecting costs
•no insurance coverage is provided

Question 11

What does “guaranteed renewable” mean?

Answer 11

•the insured has the right to continue the LTC insurance in force by timely payment of premiums & the insurer may NOT change the policy, although premium rates may be revised on a class basis

Question 12

What are the nonforfeiture benefits?

Answer 12

•no insurer may offer a LTC policy unless the policy provides some type of nonforfeiture value, such as paid-up insurance
•the reduced paid-up percentages may apply to nursing home benefits only or to all benefits
•the percentages must appear in the policy & may change based on experience but only if the policy states that a change will only be made in conjunction with a premium increase

Question 13

What is the LTC tax credit?

Answer 13

•NYS tax code allows individuals to take a credit against taxes due in the amount of 20% of the premium paid during that tax year for a LTC policy
Ex. If an individual paid a $1,000 annual premium for a LTC policy, the individual would have a tax credit of $200 & could subtract that amount from the state taxes the individual would otherwise have to pay

•the tax credit may not be used to reduce the individual’s taxes to an amount that is less than the minimum required by state law, but any unused portion of the LTC tax credit may be carried over & used in a future year

Question 14

What are the different types of LTC insurance policy riders?

Answer 14

1. Return of premium rider-provided policyowners with a refund of all or some of the premiums in certain circumstances
2. Lapse-the policyowner lapses the policy
3. Death-the insured dies without requiring the services covered by the policy
   Ex. Death occurs immediately following a car accident or heart attack
4. Shared care rider-available to married couples insured by the same company
   —>gives insured spouses the option to use on another’s LTC insurance benefit if their own benefit runs out

Question 15

What is the minimum requirement for nursing home care coverage?

Answer 15

Not less than a lifetime max total of 36 months for each covered person

Question 16

What is the inflation protection requirement?

Answer 16

•qualified policies & certificates must offer to provide lifetime inflation protection of 5% compounded on an annual calendar or policy year basis
•step rate premiums, policy & certificate options to increase benefits, or any premium payment desire where the premium rate rises automatically after issuance shall not be permitted
•premiums for qualifying policies & certificates shall be level for the duration of the policy except where a rate increase is granted by the superintendent of insurance for all persons covered by a specific policy & certificate form

Question 17

What are the elimination periods?

Answer 17

•no greater than 100 days for qualified partnership policies & certificates
•only a single elimination period for all covered services will be permitted
•commencement of a new elimination period is permitted only when a period of care is separated from another period of care by more than 6 months

Question 18

What is the Medicaid Estate Recovery Act (OBRA 1993)?

Answer 18

•the amount the department of health & human services recovers from the estate of any recipient shall not exceed the amount of medical assistance made on behalf of the recipient & shall be recoverable only for medical care services prescribed

•the concept of the NYS partnership is that after LTC policy benefit maximums have been reached, insureds will then use Medicaid Extension
•the insured will contribute income toward the cost of their care as usual under Medicaid but may protect their assets from recovery, depending on the partnership plan purchased

Question 19

What are total asset protection plans?

Answer 19

•allow policyholders to protect all of their assets
•policyholders avoid any penalty associated with asset transfers before, during, or after applying for Medicaid
•assets no longer impact their eligibility

Question 20

What are dollar-for-dollar asset protection plans?

Answer 20

•provide similar but limited protection (similar to total asset protection plans, but limited)
•protect assets equal to the amount of insurance benefits paid out
•unprotected assets in excess of the amount of partnership benefits received must be spent down, in order for an insured to be eligible for Medicaid benefits

Question 21

What is a small employer in NY?

Answer 21

•between 1-50 eligible employees, exclusive of dependents & spouses

Question 22

What does community rating mean?

Answer 22

•the premium for all persons in the covered group is the same based on the experience of the entire pool of risks covered by the policy regardless of age, sex, health, tobacco usage, or occupation

Question 23

What is the NYS Disability Benefits Law (DBL)?

Answer 23

•mandates disability benefits for eligible employees who lose their wages because of a disability caused by a nonoccupational injury or illness
•administered by the chairman of the Workers’ Compensation Board of NYS
•in general, employees compensated for services & working under an employer-employee relationship are covered by this law
•unemployed workers may also be eligible for benefits if they become disabled while unemployed

Question 24

What types of employees are excluded under the NYS Disability Benefits Law (DBL)?

Answer 24

• a domestic or personal worker in a private home who is employed for less than 40 hours per week by any one employer;
the minor child of the employer;
• farm laborers;
• licensed ministers, priests, rabbis, and certain other religious personnel;
• those in a professional or teaching capacity in a religious, charitable, or educational institution;
• independent contractors;
• persons in casual employment for less than 45 days in a calendar year;
an executive officer of a corporation who at all times during the period involved owns all of the corporate stock;
an executive officer of an incorporated religious, charitable, or educational institution;
• golf caddies;
• employees covered under the General Maritime Law or the Federal Railroad Unemployment Insurance Act;
employees of the state, another municipal corporation, local government agency, or other political subdivision, unless such employer unit has elected to be a covered
employer;
• elementary or secondary school students regularly attending classes (workers compensation is excluded for both part-time and employment during vacation périods); e
• licensed real estate brokers or sales associates if most of the person’s compensation is related to sales and there is a written contract between the person and the emp
as specified in the law

Question 25

How is an employee eligible for benefits under the NYS Disability Benefits Law (DBL)?

Answer 25

•must have been in the employe of a covered employer at least 4 consecutive weeks before the disability
•benefits not payable for any disability that begins during this 4-week period
•an employee who has satisfied the 4-week period continues to be eligible for benefits for a period of 4 weeks after employment terminated

Question 26

What are the benefit payments under the NYS Disability Benefits Law (DBL)?

Answer 26

•disabled workers whose employment was terminated & who meet the eligibility requirements will receive up to 1/2 of their average weekly wage during the period of disability
•first payment is due on the 14th day of disability & must be paid directly to the disabled person within 4 days
•benefits payable biweekly thereafter
•benefit payments may not extend beyond 26 weeks in any 52-week period
•if a worker is disabled during employment, benefits begin on the 8th consecutive day of disability
•benefit payments may not extend beyond 26 weeks in any 52-week period
•the worker receives a weekly benefit equal to 1/2 of his weekly wage, but no more then $170
—>if the weekly wage is less than $20, the benefit will equal the weekly wage
•written notice & proof of disability must be furnished by disabled employees to their employers within 30 days after the start of a disability
•as long as the disability continues, subsequent proof may be required, but no more frequently than once a week
•if requested by the employer or insurer providing disability coverage, disabled employees can be required to undergo a medical examination by a practitioner selected by the employer or insurer
•refusal by an employee to submit to an examination may be grounds to refuse benefits
•in cases when benefits are educated, the employer or insurer must send notice of the rejection to the disabled employee within 45 & by first-class mail
•a person whose employment with a covered employer is terminated & who loses unemployment benefits because he becomes disabled is entitled to receive disability benefits
•the individual will receive benefits every week for which he would have received unemployment insurance benefits if not disabled

Question 27

How can an employee who is denied benefits appeal with the chairman?

Answer 27

•appeal must be filed within 26 weeks of the notice of the rejection-chairman may excuse this time limit if the employee can demonstrate a reason for the delay
•considering the appeal, the chairman may request copies of relevant attending physicians’ statements, wage & employment data, and all other papers in the possession of the employment or insurer with respect to the claim

Question 28

What is the contribution to premium cost?

Answer 28

•employee contributions are calculated at 0.5% of wages paid, not to exceed $0.50 per week
•employers must contribute the remainder of the premium

Question 29

What are the methods of providing coverage?

Answer 29

Under disability benefits law, an employer is held responsible for providing disability benefits by:

•insuring the payment of benefits through the special state fund
•insuring the payment of benefits with an insurer authorized to transact accident & health insurance business in NY
OR
•self-funding the benefits under a plan approved by the chairman of the Workers’ Compensation Board

Question 30

What are the inalienable rights?

Answer 30

•no employee may be required or permitted to waive rights to benefits under this plan, except for employees who are receiving Social Security retirement benefits
•Social Security retirement benefit recipients may waive coverage under this plan & will be excused from the employee contribution requirement

Question 31

What is the penalty for an employer failing to provide for disability benefits as required by law within 10 days after the employee becomes a covered employee?

Answer 31

Employer is guilty of a misdemeanor

Question 32

What is the NY State of Health?

Answer 32

•health insurance exchange created by NY
•organized marketplace designed to help people shop for & enroll in health insurance coverage
•individuals, families, & small businesses can use the Marketplace to help compare insurance options, calculate costs & select coverage online, in-person, over the phone, or by mail
•helot people check their eligibility for health care programs like Medicaid & sign up for these programs if they’re eligible
•tells what type of financial assistance is available to applicants to help them afford health insurance purchased through the Marketplace

Question 33

What are essential health benefits (EHBs)?

Answer 33

•a set of health care service categories that must be covered by all individual & small group health plans subject to the PPACA
•must include items & services within at least the following 10 categories:
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity & newborn care
5. Mental health & substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative & habilitative services & devices
8. Laboratory services
9. Preventive & wellness services & chronic disease management
10. Pediatric services, including oral & vision care

Question 34

What is the Family & Medical Leave Act (FMLA)?

Answer 34

•federal law
•entitled eligible employees who work for covered employers (other than state, federal, or local governments) to take up to 12 weeks of unpaid, job-protected leave for any of the following reasons:
-birth & to care & bone with a newly born, adopted, or foster child
-member with a serious health condition
-medical leave when the employer is unable to work because of a serious health condition
-to assist when a family member is deployed abroad on active military duty

•when an employee returns from FMLA leave, they must be restored to the same job or to an equivalent job
•if an employee is provided group health insurance, the employee is entitled to continue group health insurance coverage during FMLA leave on the same terms as if they had continued to work
•the employee must continue to make any normal contributions to the cost of the health insurance premiums

Question 35

NY FMLA?

Answer 35

•covered employees may take up to 10 weeks of paid family leave
•number of weeks increases annually
•full-time employees must work at least 16 consecutive weeks
•part-time workers must be employed at least 175 days
•employees receive up to 55% of their average weekly wage, up to 55% of the statewide average weekly wage
•the % of average weekly wages increases annually
•paid family leave may be taken all at once or incrementally

Question 36

Medicaid child health plus

Answer 36

•NY’s Medicaid program provides subsidies to pay for medical care for individuals who are not otherwise covered by health insurance & who meet low-income tests based on poverty levels established by the U.S. Dept of health & Human Services

•child health plus-depends on a family’s income
-children may be eligible to join either Children’s Medicaid or Child Health Plus
-both are available through dozens of providers throughout the state

Question 37

What are the flexible spending account (FSA) contribution limits?

Answer 37

•in 2022
•employees can contribute $2,850 to their flexible spending account
—>this is an increase of $100 over the prior year
•amounts contributed are NOT subject to federal income tax, social security tax, or Medicare tax

Question 38

What are the health savings account (HSA) contribution limits?

Answer 38

•in 2022
•HSA contribution limit for individuals with a family high-deductible health plan (HDHP) coverage is $7,300
•contribution limit for self-only HDHP coverage is $3,650

Question 39

Major medical insurance

Answer 39

•provides coverage for each covered person for the following services up to a maximum of not less than $100,000, subject to a stated deductible & a coinsurance up to 25%:

•daily room & board
•miscellaneous hospital services
•surgical services
•anesthetic services
•in-hospital medical services
•mental health care coverage for at least 30 days per year of inpatient hospitalization, 30 outpatient visits per year at no less than $30 per visit & a yearly maximum of up to $1,500, & outpatient crisis intervention services consisting of at least 3 psychiatric emergency visits per year
•our-of-hospital care consisting of physicians’ services rendered on an ambulatory basis
•prosthetic appliances

Question 40

What is prospective review?

Answer 40

•insurer reviews all proposed nonemergency hospital admissions & requires pre approval before the subscriber can be admitted
•as part of this process, the insurer may require a second surgical opinion
•if the subscriber fails to get a required second opinion, the benefits for the surgery will be reduced
•if the insurer waived its right to ask for a second opinion, the benefits will be paid in full

Question 41

What is concurrent review?

Answer 41

•the insurer monitors a subscriber’s hospital stay while in progress to anticipate any changes in his medical condition that might require additional care

Question 42

What is retrospective review?

Answer 42

•type of utilization review that occurs after the medical services in question have already been provided
•used to sermons the medical necessity of the services provided & the appropriateness of medical coding for both diagnosis & procedure