Group underwriting, eligibility, contributory and noncontributory plans, COBRA and coordination of benefits are covered in the national Group Health Insurance guide. This guide covers New York's group health rules (Insurance Law 3221 and 4235): participation requirements, the 36-month state continuation right, conversion, the young adult option to age 29, and claim provisions.

Eligible groups and participation

• Group health must cover an eligible group, most commonly employer and employees (Ins. Law 3221).
• A contributory employer group for hospital or medical coverage must insure at least 50% of eligible employees, or 50 or more employees if that's fewer (Ins. Law 4235(c)(1)(A)).
• An association group must have existed at least two years and been formed mainly for purposes other than buying insurance (4235(c)(1)(B)).
• Small group for community rating means 1 to 100 employees (Ins. Law 3231(a)(1)).

State continuation (Ins. Law 3221(m))

• An employee or dependent who loses group coverage may continue it for up to 36 months.
• The written election and first monthly premium are due within 60 days of the date coverage would otherwise end.
• The premium can't exceed 102% of the group rate.

Conversion (Ins. Law 3221(e); 4304)

An employee whose group hospital, medical or surgical coverage ends may get a converted individual policy without evidence of insurability by applying within 60 days after the group coverage ends.

Young adult option (Ins. Law 3221(r); 4305)

• An unmarried child through age 29 may continue on a parent's group coverage if the child isn't eligible for employer coverage, lives, works or resides in New York, and isn't on Medicare.
• The election is made within 60 days after coverage would end at the limiting age, within 60 days of becoming eligible, or during an annual 30-day open enrollment.
• The employer doesn't have to pay any of the cost.

Claim provisions in group A&H

• Non-loss-of-time benefits are paid within 60 days after proof. Loss-of-time benefits are paid at least monthly (Ins. Law 3221(a)(12)).
• No lawsuit earlier than 60 days after proof of loss or later than two years after proof was required (Ins. Law 3221(a)(14)). (Individual policies allow three years.)

Coordination of benefits

New York's coordination of benefits rules (Regulation 62, 11 NYCRR 52.23) keep a person from collecting more than the actual allowable expenses from more than one plan.

Common exam traps

• State continuation: 36 months, elect within 60 days, pay up to 102%.
• Conversion: 60 days, no evidence of insurability.
• Young adult option through age 29, unmarried, with no employer contribution required.
• Group lawsuits: within 2 years after proof is required, not 3.
• Contributory groups: at least 50% of eligible employees, or 50 employees if fewer.