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
Universal Citation: 11 NY Comp Codes Rules and Regs ยง 360.3
Current through Register Vol. 46, No. 12, March 20, 2024
(a) No insurer may restrict or limit eligibility for individual or small group policies except in the following ways:
(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.
(i) Small group health insurance policies may
be issued to cover only certain classes of employees as provided in section
4235(c)(1)(A) based upon conditions pertaining to employment, but only if the
employer requesting coverage seeks coverage for only such classes.
(ii) Minimum participation requirements as
set forth in section 4235(c)(1) must continue to be utilized. Health
maintenance organizations may not establish any minimum participation
requirements within a group and must accept one person within a small group who
elects the HMO coverage.
(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:
(i) the individual was
covered under another plan or policy at the time the individual was initially
eligible to enroll and has lost coverage under the other plan or policy as a
result of exhaustion of the period of continuation under State or Federal law;
the loss of eligibility for one or more of the reasons specified in section
3221(q)(5)(B)(ii) or
4305(k)(5)(B)(ii) of the
Insurance Law; or termination by the plan sponsor or policyholder of
contributions toward the payment of premium for the other plan or policy,
provided the individual applies for enrollment within 30 days after termination
of coverage provided under the other plan or policy;
(ii) a court has ordered coverage be provided
for a spouse or minor children under a covered employee or member's health
benefit plan and the request for enrollment is made within 30 days after
issuance of the court order; or
(iii) any Federal or State law requires that
coverage be provided under the policy without regard to the enrollment period
specified in the policy, provided the individual applies for enrollment within
30 days after the occurrence of the event triggering the right to enroll or
within any time period specified in the law requiring the coverage, whichever
is longer.
(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.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.