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New York Rules On Group Health Access Limit

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State-regulated group health plans in New York cannot deny coverage to employees or employees’ spouses simply because the employees or spouses have access to other coverage.

Officials in the Office of General Counsel at the New York State Insurance Department have expressed that view in OGC Opinion Number 10-02-02.

The department has no role in interpreting the Employee Retirement Income Security Act, officials note in the opinion.

But an insurer regulated by New York “may not issue a group health insurance policy to an employer that makes employees and their spouses ineligible for healthcare benefits, simply because other sources of healthcare coverage are available to them,” officials write.

But an insurer that sells a group health plan can include a “coordination of benefits” provision, which may state that the insurer will look only at the amount left over after another insurer has processed a claim when making its own decision about how to handle the claim.

A copy of the opinion about group health plans and treatment of availability of alternative coverage is available here.


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