Plan types (indemnity, HMO, PPO, POS, HDHP/HSA), cost sharing and the federal Affordable Care Act rules are covered in the national Medical Plans guide. This guide covers what New York adds: community rating and open enrollment, mandated benefits, the managed care appeal rules, prompt pay, Healthy NY, and the state marketplace. Citations are to the New York Insurance Law unless noted.

Community rating and open enrollment

• Community rating: everyone covered under a policy form pays the same premium, without regard to age, sex, health status, tobacco use or occupation (Ins. Law 3231(a)(4)).
• Small group means 1 to 100 employees, not counting spouses and dependents (since 2016; Ins. Law 3231(a)(1)).
• Individuals and small groups applying for hospital or medical coverage must be accepted at all times during the year, and once accepted can't be dropped because of claims (Ins. Law 3231(a)(2), (3)).
• Community-rated premium rates need the Superintendent's prior approval (Ins. Law 3231; 4308).
• No pre-existing condition exclusions are allowed in comprehensive coverage (42 U.S.C. 300gg-3; Ins. Law 3232).
• Misstatements: for hospital, medical, surgical or prescription drug coverage, a misrepresentation must be both material and intentional to void the policy (Ins. Law 3105(b)(2)).

Mandated benefits

• Maternity stays of at least 48 hours after a vaginal delivery and 96 hours after a cesarean, unless the mother agrees to leave earlier. Early discharge triggers at least one home care visit with no cost sharing (Ins. Law 3221(k)(5)).
• Mammograms: a baseline at 35 to 39, and every year at 40 and older, or at any age with a personal or family history of breast cancer (Ins. Law 3221(l)(11)).
• Mental health parity under Timothy's Law, including services by licensed clinical social workers, mental health counselors, marriage and family therapists and psychoanalysts (Ins. Law 3221(l)).
• Autism spectrum disorder screening, diagnosis and treatment; contraceptive drugs and devices; colorectal cancer screening (Ins. Law 3216, 3221, 4303).
• Infertility diagnosis and treatment in group policies, and three cycles of IVF in large-group policies (Ins. Law 3221(k)(6)(C)).

Managed care protections

• Emergency care is covered under the prudent layperson standard (Ins. Law 4900(c)).
• Prior authorization decisions are made by phone and in writing within three business days of getting the needed information. Plans must offer a step therapy override process (Ins. Law 4903).
• Internal appeals: members get at least 45 days to file. The plan acknowledges within 15 days and decides within 30 days of getting the needed information (Ins. Law 4904(c)).
• External appeals: a member may ask for an independent external appeal within four months of a final denial for lack of medical necessity or as experimental. Standard appeals are decided within 30 days, expedited ones within 72 hours, and the plan pays the cost (Ins. Law 4910, 4914).
• People with serious conditions can get a standing referral to a specialist (Ins. Law 4804). Women have direct access to a participating OB/GYN (Public Health Law 4406-b).
• HMOs are certified under Public Health Law Article 44, with DFS regulating their rates and solvency.

Prompt pay

Undisputed (clear) claims are paid within 30 days if submitted electronically or 45 days if submitted on paper or by fax (Ins. Law 3224-a(a)).

Dependents and the young adult option

• A child is a dependent until 26 for hospital, medical, surgical or prescription drug coverage, regardless of marriage, residence, student status or employment (Ins. Law 3216(a)(4)).
• Young adult option: an unmarried child through age 29 who isn't eligible for employer coverage, lives, works or resides in New York, and isn't on Medicare can continue on a parent's group policy. The employer doesn't have to pay for it (Ins. Law 3221(r); 4305).
• A newborn is covered from birth, including congenital defects, with at least 30 days to give any required notice or premium (Ins. Law 3216(c)(4)(C)).

Healthy NY and public programs

• Healthy NY (Ins. Law 4326) offers coverage to qualifying small employers: no more than 50 employees, no group health coverage in the past 12 months, and at least 30% of employees earning at or below an indexed wage. HMOs must participate; other insurers may.
• NY State of Health is New York's own official health plan marketplace.
• Child Health Plus covers children under 19 who aren't eligible for Medicaid, with subsidies based on household income (Public Health Law 2510, 2511).

Common exam traps

• Community rating ignores age, sex, health, tobacco and occupation.
• Small group is 1 to 100 employees in New York.
• Young adult option to age 29, at no cost to the employer.
• External appeal: 4 months to file; 30 days standard, 72 hours expedited.
• Prompt pay: 30 days electronic, 45 days paper.
• Healthy NY: 50 or fewer employees, no coverage for 12 months, 30% lower-wage workers.