New York Health Study Guide

New York did not simply adopt the federal health-care floor and stop. It built a state exchange on top of it, priced individual and small-group coverage on a rating rule stricter than the ACA’s own, gave members an external appeal that actually binds the plan, and rewrote continuation coverage so completely that the federal numbers you memorised are the wrong answers here. That last point is worth sitting with, because it is where most candidates lose marks on this exam.

The marketplace — and the plan underneath it

New York runs a state-based exchange, NY State of Health, not healthcare.gov. It is a single front door: the same application enrols people into qualified health plans, Medicaid, Child Health Plus (the state’s CHIP programme), and the Essential Plan. Medicaid expanded here to 138% of the federal poverty level, effective 1 January 2014, and is administered by the Department of Health rather than by DFS.

Then the rating rule. New York uses pure community rating on individual and small-group medical. Section 3231(a) requires premiums set “without regard to age, sex, health status, tobacco usage or occupation.” That is stricter than the ACA, which permits a 3-to-1 age band and a tobacco surcharge — and it is the reason a 25-year-old and a 60-year-old in the same New York plan pay the same premium.

Prompt pay — one deadline is never the answer

Most states publish a single clean-claim payment deadline. New York publishes two, and which one applies depends entirely on how the claim arrived. Under Insurance Law § 3224-a, a clean claim submitted electronically must be paid within 30 days; a clean claim submitted on paper — or by any other non-electronic route — gets 45 days. Miss either and interest runs at the greater of the Commissioner of Taxation and Finance’s corporate-tax rate or 12% a year — 12% is the floor, not a ceiling.

External appeal — and the word “binding”

New York’s external appeal is administered by DFS and decided by a certified independent external appeal agent, and its decision is binding on the health plan and on the insured (§ 4914) — it settles the dispute in both directions rather than giving the member a free option. A member files within four months of the final adverse determination and gets a decision in 30 days, or 72 hours on an expedited review. Where other states’ external review is advisory or narrowly scoped, New York’s simply overrides the plan.

Continuation — throw the federal numbers away

This is the section to over-learn, because everything you know about COBRA points the wrong way. Federal COBRA applies at 20 or more employees and runs 18 months, 29 with disability, 36 for certain dependent events. New York flattens all of it.

State continuation reaches groups with fewer than 20 employees — below the federal threshold — and extends federal COBRA for the larger ones. And the duration is the same regardless: up to 36 months, for every qualifying event, at every employer size. The election period is 60 days from the qualifying event or notice, and the premium is capped at 102% of the group rate.

Long-term care — what New York does not require

Long-term care products sit inside the Accident & Health line; New York issues no separate LTC credential. And contrary to a claim you will see repeated widely, New York insurance law imposes no LTC training requirement. DFS has said so directly in a formal opinion: the Insurance Law and regulations do not require training or certification in order to be paid commissions on New York Partnership for Long Term Care products. Partnership-specific training does exist — but it comes from the Department of Health and the participating insurers, not from the insurance regulator, and it applies only to Partnership-qualified policies rather than to long-term care generally.

The LTC free look is 30 days from delivery, under Regulation 62.