• Your Protections When Buying Individual Health Insurance
• Your Protections as a Small Employer
• Legislation and Regulation

• Companies that sell individual health insurance in New York State are not permitted to turn you down because of your health status and other factors. 
  
  
• If you buy an individual health plan, there are limits on pre-existing condition exclusion periods that can be imposed. There are rules about what counts as a pre-existing condition and how long you must wait before a new health plan will begin to pay for care for that condition. Generally, if you join a new plan, your old coverage will be credited toward the pre-existing condition exclusion period, provided you did not have a break in coverage of more than 63 calendar days.
  
  
• Insurers that sell individual health insurance must offer family coverage to persons who are interested in purchasing it.
  
  
• HMOs must offer a standardized policy to all consumers. You may select either the HMO or the point-of-service (POS) version of the policy.
  
  
• Your coverage cannot be canceled because you get sick. This is called  "guaranteed renewability".
  
  
• Your premiums cannot be increased because of your claims experience.
  
  
• The sole proprietor health law created a new premium rate for sole proprietors that is significantly lower than individual direct pay rates.² It requires health insurers that offer group coverage through New York's chambers of commerce or association groups to provide the same policies to sole proprietors. The rate charged to sole proprietors must be within 20 percent of small group rates.
  
  
• Some individuals buy health insurance through professional or trade associations. The laws applying to association health coverage can be different than those for other health plans. Check with the New York Insurance Department about your protections involving association health plans.

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• With few exceptions, small employers cannot be refused the opportunity to buy health insurance. This is called "guaranteed issue." If you employ at least 2 but not more than 50 people, health insurance companies must sell you any small group health plan they sell to other small employers. HMOs cannot require that a minimum percentage of your eligible employees participate in your group health plan, but other insurers are allowed to set such requirements.
  
  
• Your insurance cannot be cancelled because someone in your group becomes sick. This is called "guaranteed renewability". Insurers can impose other conditions, however. For example, they can require you to meet minimum participation and contribution rates in order to renew your coverage.
  
  
• Premiums for all health plans sold to small employers in New York are community rated. This means your premium cannot vary due to the health status, claims experience, age, gender, or occupation of people in your group. Premiums may vary due to family size and geographic location.
  
  
• Some small employers buy health insurance through professional or trade associations. The laws applying to association health coverage can be different than those for other health plans. Check with the New York Insurance Department about your protections involving association health plans.

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• TEFRA (Tax Equality and Fiscal Responsibility Act of 1982, Revised 1986)
  Employers of 20 or more full- or part-time employees are responsible for providing the same coverage to working employees age 65 or older (TEFRA) and their non-working spouses age 65 or older (DEFRA) as they provide for employees under 65.
  
  
• COBRA (Consolidated Omnibus Budget Reconciliation Act of 1988, 1989)
  Employers of 20 or more employees maintaining a group health plan are required to offer employees and their dependents the option of continuing membership in the group plan at their own expense after they leave employment under certain circumstances. The cost of the COBRA extension can be charged to the employee at 102 percent of the group's cost for an active employee. Furthermore, the law adds a "portability" feature to coverage wherein an insurer must credit the time a person was covered under a prior health insurance policy toward satisfying any pre-existing condition waiting period imposed by the subsequent policy. To be creditable coverage, the prior coverage must have been in force at least 63 calendar days before the effective date of the subsequent policy.
  
  New York State law also provides a continuation right for health plans that are not subject to COBRA. Insurance Law Sections 3221(m) and 4305(e), which set forth the right to continuation, apply to groups of twenty or fewer employees and to cases where an employee is not eligible for benefits under COBRA. The rights afforded by those statutes apply only to group policies providing hospital, surgical or medical expense insurance and arise when all or any portion of the insurance on an employee ceases because of termination of employment or membership in the class or classes eligible for coverage under the policy. If such an event occurs, the employee is entitled to a right of continuation provided that they are not eligible for identical coverage with another plan. The employee must also request continuation coverage and pay the applicable premium within the timeframes set forth in the statutes.