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 360.4 - Open enrollment for individual and small group health insurance policies

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The effective
				date provisions of chapter 501 of the Laws of 1992 provide that the
				requirements of that law, including both community rating and open enrollment,
				apply not only to newly issued policies, but also to previously issued
				policies. However, the superintendent is also granted authority and
				responsibility to promulgate regulations to ensure orderly implementation of
				community rating and open enrollment. In order to fulfill this responsibility
				the department believes that insurers should be permitted to continue to serve
				certain previously issued policies without having to accept new applicants for
				older policies on an open enrollment basis. Certain provisions of this section
				are designed to implement rules for orderly implementation that explain how the
				requirements of chapter 501 of the Laws of 1992 shall apply to new and
				previously issued policies.
(b)
				Insurers, other than health maintenance organizations, are not required to
				offer policies of individual insurance. For those insurers choosing to do so,
				all applicants must be accepted subject to permissible eligibility rules set
				forth in this Part and no applicant may be rejected based on failure to apply
				for, purchase or be accepted for another type of insurance coverage. Individual
				proprietors may be classified in the individual rating category by the insurer,
				but any such classification must be consistently applied to all individual
				proprietors.
(c) Insurers, other
				than health maintenance organizations, are not required to offer small group
				policies. For those insurers choosing to do so coverage must be offered to all
				small groups comprised of two to 50 employees or members and all applicants
				must be accepted subject to permissible eligibility rules set forth in this
				Part, and no applicant may be rejected based on a failure to apply for,
				purchase or be accepted for another type of insurance coverage. Insurers may
				choose to classify individual proprietors within the small group category
				provided that any such classification is applied consistently to all individual
				proprietors. No insurer may limit the issuance of any policy form to small
				groups of certain sizes, such as only groups of 25 to 50.
(d) Issuing individual or group policies
				pursuant to a statutory or contractual right of conversion shall not be
				considered offering individual or group insurance for purposes of the open
				enrollment provisions of sections 3231 and
				4317  of the Insurance Law.
(e) The provisions of chapter 501 of the Laws
				of 1992 shall not apply to individual policies that are guaranteed renewable,
				as that term is defined in sections
				52.17(a)(5)
				or (6) and
				58.1(b)(1) 
				of this Title and to individual noncancellable policies that are delivered or
				issued for delivery prior to February 1, 1993, unless such policies are issued
				by the insurer on or after said date.
(f) For new and existing policies not subject
				to subdivision (e) of this section, the provisions of chapter 501 are
				applicable, however:
(1) for community-rated
				policies sold only on an open enrollment basis an insurer may continue to renew
				the policies without accepting any new applicants for such policies;
(2) for existing policies not sold after July
				17, 1992, the insurer must community rate such policies but need not accept any
				new applicants for such policies, however, an insurer may request an exemption
				from the community rating requirement, subject to approval of the
				superintendent, upon a showing that the policy involved has not been sold for a
				significant period of time and either covers a very small number of individuals
				or has been subsidized by the insurer for an extended period of time;
(3) policies or certificates may be issued on
				an open enrollment basis to new entrants to groups covered under existing
				policies not sold after July 17, 1992 and such issuance will not require that
				the insurer accept any new applicants for such policies;
(4) for existing policies sold after July 17,
				1992, other than those qualifying under paragraph (1) of this subdivision, such
				existing policies must be offered on an open enrollment basis after April 1,
				1993 unless the insurer discontinues or terminates all such policies in force
				with individuals or small groups; and
(5) in the case of association groups, the
				term sold in paragraphs (2), (3) and (4) of this subdivision shall include the
				addition of any new member employers or other member groups to the association
				coverage.