New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter XIV - Individual And Small Group Health Insurance › Part 362 - The Healthy New York Program And The Direct Payment Stop Loss Relief Program › Subpart 362-4 - Rules Relating To Working Uninsured Individuals And Individual Proprietor Participation › Section 362-4.2 - Working uninsured individuals and individual proprietor participation

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Qualifying
				  individuals shall in no case include individuals who have health insurance in
				  force or who would be eligible to obtain health insurance under an employer
				  provided group health benefits plan. Qualifying small employers shall in no
				  case include individual proprietors who have health insurance in force or who
				  would be eligible to obtain health insurance under an employer provided group
				  health benefits plan.
(b) An
				  applicant would be considered eligible for an employer provided group health
				  benefits plan if they are eligible to participate in an employer sponsored
				  health benefit plan (insured or self-insured) and the employer contributes
				  toward the cost of the plan or the payment of the premium.
(c) A working uninsured individual or
				  individual proprietor applicant shall not be denied eligibility for the Healthy
				  New York Program on the basis that their employer provides coverage if the
				  applicant is precluded from participation in the employer sponsored health
				  benefits plan due to conditions of eligibility which are based upon conditions
				  pertaining to employment, as defined in section
				  52.18(f) 
				  of this Title.
(d) A working
				  uninsured individual or an individual proprietor shall be eligible for the
				  Healthy New York Program without regard to the existence of health insurance
				  coverage during the 12-month period preceding application if such health
				  insurance coverage terminated due to one of the events listed in section 4326 (c)(3)(C)  of the
				  Insurance Law, provided that the applicant has not obtained other health
				  insurance coverage subsequent to such termination.
(e) A working uninsured individual or an
				  individual proprietor shall be eligible for the Healthy New York Program
				  without regard to the existence of health insurance coverage during the
				  12-month period preceding application if such health insurance coverage
				  terminated due to reaching the age of dependency under such prior coverage,
				  provided that the applicant has not obtained other health insurance coverage
				  subsequent to such termination.
(f)
				  Mid-year fluctuations in household income or employment status shall not serve
				  as a basis for termination of a qualifying health insurance contract.
(g) Working uninsured individuals and
				  individual proprietors must be residents of New York State in order to qualify
				  to purchase a qualifying health insurance contract. Documentation of New York
				  State residency must be provided at initial application.
(h) Qualifying health insurance contracts
				  shall be subject to all applicable conversion rights including those described
				  in sections 3216 (c)(5), 3221 (m), 4304 (e) and
				  4305 (d)  of the Insurance
				  Law. A member covered under a qualifying health insurance contract who elects
				  to exercise a statutory conversion right shall be provided with the option of
				  converting directly to a qualifying individual health insurance contract if
				  such member satisfies the eligibility criteria set forth in section 4326 (c)(3)(ii)-(iv)  of the
				  Insurance Law.
(i) Upon initial
				  application, health maintenance organizations and participating insurers shall
				  collect and examine documentation sufficient to demonstrate eligibility for a
				  qualifying health insurance contract and compliance with the terms of the
				  Healthy New York Program. Appropriate forms of documentation shall, at a
				  minimum, include:
(1) proof of
				  residency;
(2) proof of employment
				  status; and
(3) proof of
				  income.