State RegulationsNY specificDifficulty 2/5
An insurer that sells health coverage in New York's small-group market receives an application from a qualifying small employer. Under Reg 145, what must the insurer do?
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Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Under Reg 145 (11 NYCRR Part 360 (Reg 145)), insurers in the New York small-group market must make coverage available to small employers that apply; every small group carrier is required to accept eligible small employer groups. Coverage cannot be refused because of the group's health status or claims experience or the medical condition of individual employees. This guaranteed availability is the foundation of the small-group market.
Why the other options are wrong
- A) The health condition of an employee can never be a reason to refuse a small employer group; availability is guaranteed.
- B) Deferral to an annual enrollment period contradicts the year-round open enrollment that Reg 145 provides in the small-group market.
- C) Medical screening of employees is not permitted; small-group coverage is not conditioned on examinations or statements of health.
Memory hook
Guaranteed availability: a small-group carrier cannot say no to a qualifying employer.