N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 362-4.2

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

Section 362-4.2 - Working uninsured individuals and individual proprietor participation

(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.

(j) Qualifying health insurance contracts shall include a provision providing for a 30-day grace period for payment of premiums.

(k) In order to purchase a qualifying individual health insurance contract, applicants must be employed persons. Applicants for qualifying individual health insurance contracts may also meet this employment requirement by demonstrating that their spouse (residing in their household) is an employed person.

N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 362-4.2