New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter XIV - Individual And Small Group Health Insurance
Part 360 - Rules To Assure An Orderly Implementation And Ongoing Operation Of Open Enrollment And Community Rating Of Individual And Small Group Health Insurance
Section 360.3 - Eligibility for individual and small group health insurance policies

(1) Insurers may issue policies only to or through groups recognized under sections 4235 (c)(1)(A) (B) (D) (H) (K) (L) and (M) and 4237 of the Insurance Law.

(2) An employer's required time period of employment before coverage under the employer's plan takes effect.

(3) A required number of work hours to qualify as an employee, not to exceed 20 hours per week.

(4) Geographical limitations as set forth in the premium rate filing and approved by the superintendent. However, limited geographic offerings of a policy in relation to the operating areas of the insurer may be disapproved by the superintendent. For example, an insurer offering small group policies throughout the State could offer a new small group policy only in the downstate region, but that insurer could not offer that policy only in one downstate county. In the case of HMOs and other managed care products with limited provider networks, the offering of the policy may be limited to the geographical area in which the provider network is located.

(5) Overinsurance rules filed with the Health and Life Policy Bureau and approved by the superintendent subsequent to the adoption of this regulation for applicants actually covered under the same or other group or individual policies.

(6) Where licensed health maintenance organizations and licensed insurers offering plans with a limited provider network have applied to the superintendent and been granted a temporary waiver of the requirement for open enrollment found in sections 3231 and 4317 of the Insurance Law upon a showing that the existing provider network is unable to provide adequate care to additional covered persons whether applying as individuals, members of small groups or members of large groups and it is not reasonably possible to expand the network to allow enrollment of any of these additional applicants. The superintendent shall review such request in consultation with the Commissioner of Health, giving consideration as to whether the request for a waiver is designed to avoid the enrollment of individuals or small groups. Applications for such waivers shall include a plan for management of membership growth and expansion of capacity, including a demonstration that all market segments are being served in a balanced fashion. Any approval of such requests will be subject to periodic updates in a frequency to be determined by the superintendent to ensure that conditions giving rise to the request continue to exist and that reasonable efforts to adjust the provider network continue to be made.

(7) Issuance of policies of Medicare supplement insurance may be conditioned upon the enrollment of the applicant in both Part A and Part B of Medicare.

(8) Where a small group offers more than one health care plan to its employees or members, rules may be established controlling the transfer between the health care plans so long as transfer is permitted no less than once each calendar year.

(9) Where an eligible employee or member or dependent or spouse of such employee or member rejects initial enrollment in a group or blanket policy that provides hospital, surgical or medical expense insurance, rules may be established limiting future enrollment to specified time periods, however, such rules shall not apply to such employee, member, dependent or spouse if:

(10) An insurer may limit changes in coverage initiated by an individual or small group, either by changing policies or adding or deleting riders, to an anniversary date or other regular interval, so long as the interval is every 12 months or less.

(11) A rule limiting eligibility where an individual or small group has had health insurance coverage terminated within the previous 12 months for failure to pay premiums.