New York mandated health benefits and offers: dependent age limits, disabled and newborn children, and HMO preventive care

Mandated benefits versus mandated offers

New York shapes health insurance in two different ways, and the exam expects you to tell them apart.

• A mandated benefit must be included in every policy of the type the law describes. The buyer cannot decline it.
• A mandated offer (New York's statutes say the insurer must make available) must be offered, but the policyholder decides whether to buy it.

Dependent coverage to age 26 is a mandated benefit. Dependent coverage through age 29 is a mandated offer.

How long a child counts as a dependent

New York's individual accident and health statute defines dependent children, and the answer depends on what kind of policy it is.

Hospital, medical, surgical or prescription drug expense policies

• Any child, married or unmarried, is a dependent until age 26.
• The insurer may not look at financial dependence, whether the child lives with the policyholder, student status or employment.

Other policies (for example, coverage that is not medical expense insurance)

• The policy may set a dependent age limit, but as a general rule it cannot exceed age 19. The exceptions below, and the disabled-child rule, can extend coverage past 19.
• An unmarried student at an accredited institution may be kept on until age 23.
• At the insurer's option, any unmarried child may be covered until age 25.

The Age 29 law

Chapter 240 of the Laws of 2009, known as the Age 29 law, lets young adults stay on, or get onto, a parent's coverage through age 29. It works in two ways.

The make-available option. An insurer whose hospital, medical or surgical policy covers dependent children must make available, and extend on request, coverage for a child through age 29. The child must be:

• unmarried (financial dependence does not matter),
• not insured by, or eligible for, an employer health plan as an employee or member, and
• living, working or residing in New York or in the insurer's service area.

In a group, the employer or group decides whether to buy this benefit. The young adult does not get that choice.

The young adult option. Through a parent's group policy, an eligible young adult can continue coverage after aging off, or elect it later on newly becoming eligible (for example, after losing group coverage). The employee or young adult elects it and pays the premium, which cannot exceed 100% of the single premium rate.

Disabled children

An unmarried child of any age stays covered if the child is incapable of self-sustaining employment because of mental illness, a developmental disability or a physical handicap, and became incapable before reaching the age at which dependent coverage would otherwise end. The child is subject only to the same pre-existing condition limitation that applies to other dependents. Insurers normally ask for proof of the incapacity around the time the child would age off, and periodically after that.

Exam trap: the disability must begin before the limiting age. A child who becomes disabled after aging off is not swept back in.

Newborn and adopted children

Under standard health insurance practice, a policy that covers dependents covers a newborn from the moment of birth, including care for illness, injury, congenital defects and premature birth. There is no waiting period. If adding the child changes the premium, the policyholder must notify the insurer and pay within a short window after the birth, commonly about a month. Adopted children are covered on the same terms.

New York also protects the delivery itself. Pregnancy coverage must pay at least two payments for prenatal care plus a separate payment for delivery and postnatal care. If the mother leaves the hospital early, the policy must cover a home care visit, requested within 48 hours of delivery (96 hours after a caesarean) and delivered within 24 hours. That visit carries no deductible, coinsurance or copayment.

HMO preventive care

A health maintenance organization is built around keeping members well. It provides care through a network, and a primary care provider acts as gatekeeper: other than emergency care, services must be provided by, or on referral from, the primary care provider. New York's statute calls a policy that works this way a managed care product.

Preventive care is the HMO's core promise. Routine physicals, immunizations, well-baby and well-child visits, and screenings are covered, with little or no cost sharing. Under the federal Affordable Care Act, non-grandfathered plans must cover recommended preventive services with no cost sharing at all.

New York also mandates specific screening benefits. For example, a policy covering hospital, surgical or medical care must cover a baseline mammogram at ages 35 to 39, annual mammograms after that, and a mammogram at any age, on a physician's recommendation, for anyone with a prior history of breast cancer or a first-degree relative with one.