N.Y. Comp. Codes R. & Regs. tit. 11 § 360.4

Current through Register Vol. 46, No. 50, December 11, 2024

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

(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.

(g) Those insurers that decide to withdraw from the individual and/or small group market by class nonrenewal or sale of the business must provide at least 180 days prior written notice of their intention to do so to the superintendent with a plan to minimize potential disruption in the market place occasioned by such withdrawal.

(h) All Medicare supplement insurance policies subject to this Part must be offered on an open enrollment basis to persons enrolled in Medicare whether enrolled by reason of age or by reason of disability.

(i) The provisions of chapter 501 of the Laws of 1992 shall not apply to a group with more than 50 eligible employees or members, even when such employees or members are covered under more than one health benefit option and less than 50 employees or members are covered under one option. This paragraph shall not be applicable in an association group case because the entire association must be community rated and open enrolled when the association includes any group of 50 or under.

(j) The applicability of the provisions of chapter 501 of the Laws of 1992 should be based on whether the group has 50 or less eligible members on the date of application for coverage or in subsequent years on the date of the determination of renewal rates. Fluctuation in the size of the group during the contract year shall not affect the applicability of such law.

N.Y. Comp. Codes R. & Regs. Tit. 11 § 360.4