N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 362-2.3

Current through Register Vol. 46, No. 43, October 23, 2024

Section 362-2.3 - Enrollment

(a) Applications for qualifying health insurance contracts shall be made directly to health maintenance organizations and participating insurers.

(b) Health maintenance organizations and participating insurers shall provide all necessary information and enrollment forms when requested by applicants.

(c) Health maintenance organizations and participating insurers shall collect the initial eligibility certifications required by section 4326 (i) of the Insurance Law and necessary supporting documentation and shall be responsible for examination of such certifications and supporting documentation for verification that applicants meet applicable eligibility requirements. Health maintenance organizations and participating insurers shall accept any standardized application form that may be prescribed by the superintendent.

(d) Unless the superintendent suspends enrollment in the Healthy New York Program pursuant to section 4327 (k) of the Insurance Law or approves a request to suspend qualifying individual enrollment pursuant to subdivision (h) of this section, all applicants meeting eligibility criteria shall be accepted and coverage must be issued on the first day of the month next succeeding the date a complete application has been submitted for all applications submitted on or prior to the 20th day of such month. For applications submitted after the 20th day of a month, coverage shall be issued no later than the first of the month next following. Dependent children up to at least age 19 and full-time students up to at least age 23 shall be considered eligible dependents under qualifying health insurance contracts.

(e) Health maintenance organizations and participating insurers shall provide applicants which have failed to demonstrate eligibility with a written notice of denial which clearly sets forth the basis for the denial.

(f) Health maintenance organizations and participating insurers must submit monthly enrollment reports which detail total enrollment in the Healthy New York Program in the format specified by the superintendent. Such reports shall identify the health maintenance organization's or participating insurer's total enrollment in the Healthy New York Program as of the first day of the following month and must be submitted to the superintendent no later than the 15th day of the following month.

(g) In the event that the enrollment in the small employer or individual Healthy New York Program is suspended pursuant to section 4327 (k) of the Insurance Law, participating insurers and health maintenance organizations shall:

(1) notify applicants that enrollment has been suspended; and

(2) maintain a waiting list to be filled in the order of receipt in the event that enrollment is reactivated.

(h) Commencing June 1, 2001, if monthly enrollment reports indicate that a given health maintenance organization or participating insurer's total enrollment under qualifying individual health insurance contracts exceeds 50 percent of that health maintenance organization's or participating insurer's total enrollment in the Healthy New York Program, the health maintenance organization or participating insurer may submit a request to the superintendent to suspend the issuance of its qualifying individual health insurance contracts. If approved by the superintendent, the suspension shall take effect on the date specified by superintendent and shall be for the period specified by the superintendent. A participating insurer or health maintenance organization that has received approval to issue such a suspension shall:

(1) notify applicants that enrollment has been suspended;

(2) maintain a waiting list to be filled in the order of receipt in the event that enrollment is reactivated; and

(3) on a quarterly basis, submit reports detailing the claims experience of the Healthy New York product. Such reports shall segregate the claims experience of qualifying individuals from the claims experience of qualifying small employers and individual proprietors.

(i) An enrollment suspension pursuant to section 4327 (k) of the Insurance Law or pursuant to subdivision (h) of this section shall not preclude the addition of dependents or new employees to existing qualifying health insurance contracts. Additionally, an enrollment suspension shall not prevent the enrollment of persons exercising a statutory right of conversion to a qualifying individual insurance contract.

(j) Nothing herein is intended to preclude, diminish or in any way impair the involvement of chambers of commerce, trade associations and other similar entities in the Healthy New York Program in any manner otherwise permitted by law or regulation.

N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 362-2.3