Key Takeaways
- New York requires a 10-day free look period for individual health insurance policies
- New York operates its own state health insurance marketplace, NY State of Health
- New York requires community rating - insurers cannot charge more based on health status
- Mental health parity is required - mental health benefits must equal medical benefits
- Pre-existing condition exclusions are prohibited in all New York health insurance markets
New York Health Insurance Policy Requirements
New York has comprehensive health insurance regulations that often exceed federal requirements. New York was a pioneer in many consumer protections now required nationally.
Regulatory Structure
New York health coverage is regulated by the Department of Financial Services:
| Agency | Regulates |
|---|---|
| DFS Insurance Division | All health insurers |
| DFS Health Bureau | Health policy compliance |
| NY State of Health | Marketplace administration |
Free Look Period
New York provides a 10-day free look period for individual health insurance:
- Policyholder can return for full premium refund
- Begins when policy is delivered
- Applies to individual health policies
- Same as life insurance free look period
Community Rating
New York requires community rating for health insurance:
What Community Rating Means
- All individuals pay the same rate regardless of health status
- Age adjustments limited (older adults cannot be charged more than 3x younger adults)
- No higher rates for pre-existing conditions
- No medical underwriting
Factors That CAN Affect Rates
| Permitted Factor | How Used |
|---|---|
| Age | Limited age bands |
| Geographic Area | Regional rate differences |
| Family Size | Individual, couple, family |
| Tobacco Use | Limited surcharge allowed |
Exam Tip: New York was one of the first states to require community rating, even before the ACA. This is a key consumer protection.
Required Coverage
New York mandates coverage for numerous benefits:
Essential Health Benefits
All individual and small group plans must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
Mental Health Parity
New York's Mental Health Parity Law (Timothy's Law) requires:
- Mental health benefits equal to medical/surgical benefits
- Same copays, deductibles, and out-of-pocket limits
- Same treatment limitations
- Covers mental illness and substance use disorders
- Applies to group and individual plans
Covered Conditions
- All mental health conditions
- Substance use disorders
- Behavioral health conditions
- Autism spectrum disorder treatment
Pre-Existing Condition Protections
New York prohibits pre-existing condition exclusions:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Prohibited |
Note: New York prohibited pre-existing condition exclusions before the federal ACA required it nationally.
NY State of Health
NY State of Health is the state's official health insurance marketplace:
- Only place to get premium tax credits
- Offers qualified health plans (QHPs)
- Administers Medicaid and Essential Plan eligibility
- Open enrollment and special enrollment periods
Key Features
- Plans categorized by metal tiers (Bronze, Silver, Gold, Platinum)
- Premium tax credits based on income
- Cost-sharing reductions for Silver plans
- Essential Plan for low-income New Yorkers
- Special enrollment for qualifying life events
Guaranteed Issue and Renewal
New York requires:
Guaranteed Issue
- Insurers must accept all applicants
- Cannot deny coverage based on health status
- Applies to all markets (individual, small group, large group)
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with notice)
What is the name of New York's official health insurance marketplace?
What does community rating mean in New York health insurance?