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11 CRR-NY 363.4NY-CRR

STATE COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK

TITLE 11. INSURANCE

CHAPTER XIV. INDIVIDUAL AND SMALL GROUP HEALTH INSURANCE AND FAMILY LEAVE BENEFITS COVERAGE

PART 363. MINIMUM STANDARDS FOR THE FORM AND RATING OF FAMILY LEAVE BENEFITS COVERAGE, INCLUDING THE ESTABLISHMENT AND OPERATION OF A RISK ADJUSTMENT MECHANISM

11 CRR-NY 363.4

363.4 Community rating and procedures for establishing rates.

(a) Community rating.

(1) Pursuant to Insurance Law section 4235(n)(1), the superintendent, in consultation with the chair, has determined that family leave benefits coverage shall be community rated.

(2) The community rate for premiums shall be established by the superintendent and shall apply statewide to all policies.

(3) The community rate for premiums shall be set each year by the superintendent as a defined amount per week per employee. The superintendent may set the community rate for premiums as a defined dollar amount per employee or as a percentage of an employee’s weekly wages. The superintendent may also utilize any one of the following three classification methodologies in setting the community rate for premiums:

(i) Classification Methodology One: The community rate for premiums may be set as three separate rates for employees earning an average weekly wage of:

(a) up to one-third of the statewide average weekly wage;

(b) more than one-third and up to two-thirds of the statewide average weekly wage; and

(ii) Classification Methodology Two: The community rate for premiums may be set as two separate rates for employees earning an average weekly wage of:

(a) up to one-half of the statewide median weekly wage; and

(b) more than one-half of the statewide median weekly wage.

(iii) Classification Methodology Three: The community rate for premiums may be set using any other series of wage classifications based on an employee’s weekly wages that the superintendent determines to reasonably differentiate employees based on their respective wages.

(4) In subparagraph (3)(i) or (ii) of this subdivision, the community rated premium or the maximum employee contribution paid by each employee shall be the amount that corresponds to the employee’s average weekly wage.

(i) Except as provided in subparagraph (ii) of this paragraph, the employee’s average weekly wage shall be calculated using the average weekly wage of the employee’s previous eight weeks of employment or portion thereof that the employee was in such employment with the same employer that is collecting the employee’s contribution. Once calculated for a calendar year, an employee’s average weekly wage shall be applicable for the remainder of the calendar year unless the employee’s wage rate, average numbers of work hours per week, or salary changes, in which case, the employee’s average weekly wage shall be recalculated on a quarterly basis on January 1st, April 1st, July 1st, and October 1st.

(ii) In the case of a self-employed person, the average weekly wage for such person shall be the greater of the person’s self-employment income, as defined in 26 U.S.C. section 1402(b), for the previous full calendar year divided by 52 weeks, or the statewide average weekly wage. If there is not 52 weeks of self-employment income for the previous full calendar year, then the person’s average weekly wage shall be the greater of the sum of the person’s wages for the previous calendar plus the person’s self-employment income, as defined in 26 U.S.C. section 1402(b), divided by 52 weeks, or the statewide average weekly wage. Once calculated for a calendar year, a self-employed person’s average weekly wage shall be applicable for the remainder of the calendar year.

(5) On or before June 1, 2017, and on or before September 1st of each year thereafter, the superintendent shall publish the community rate for premiums for the policy benefit period beginning on the following January 1st. The community rate for premiums shall also be the maximum employee contribution regardless of whether the family leave benefits are provided by an issuer or a self-funded employer.

(b) Procedures for establishing rates.

(1) In accordance with Insurance Law section 4235(n)(1), in establishing the community rate for premiums, the superintendent shall apply commonly accepted actuarial principles to establish community rated family leave benefits coverage rates that are not excessive, inadequate or unfairly discriminatory.

(2) In establishing the community rate for premiums, the superintendent may use data collected for the previous calendar year from all issuers and self-funded employers. In addition to any information requested by the superintendent or the chair pursuant to Workers’ Compensation Law section 208(2), issuers and self-funded employers shall report the data as required by section 363.8 of this Part.

(1) Every issuer shall file and maintain a current rate manual of this State that includes the following information for a policy providing family leave benefits:

(i) the name of issuer and policy form number on each page;

(ii) a description of the benefits under the policy, separately describing the benefits provided pursuant to Workers’ Compensation Law section 204(2) and any additional or enhanced benefits beyond those specified in section 204(2);

(iii) a schedule of the premium rates for any additional or enhanced benefits beyond those specified in Workers’ Compensation Law section 204(2); and

(iv) a schedule of expenses as a percentage of premium, including administrative expenses, commissions, taxes, fees and expected profit.

(2) The information required by paragraph (1) of this subdivision shall be included in separate rate manual pages for each of the three group sizes referenced in section 363.5(g)(1) of this Part.

(3) The rate manual pages for family leave benefits shall be separately maintained from the rate manual pages for all other types of insurance including disability benefits provided pursuant to article 9 of the Workers’ Compensation Law.

(4) The rate manual pages shall be included as part of a rate filing submitted to the superintendent. The rate filing shall include an actuarial memorandum that includes justification of the schedules referenced in subparagraphs (1)(iii) and (iv) of this subdivision, as applicable.

11 CRR-NY 363.4

Current through May 31, 2021

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