subpart 3—provisions applicable only to health insurance issuers
Amendments
1996—
Subpart Referred to in Other Sections
This subpart is referred to in
§300gg–11. Guaranteed availability of coverage for employers in group market
(a) Issuance of coverage in small group market
(1) In general
Subject to subsections (c) through (f) of this section, each health insurance issuer that offers health insurance coverage in the small group market in a State—
(A) must accept every small employer (as defined in
(B) must accept for enrollment under such coverage every eligible individual (as defined in paragraph (2)) who applies for enrollment during the period in which the individual first becomes eligible to enroll under the terms of the group health plan and may not place any restriction which is inconsistent with
(2) "Eligible individual" defined
For purposes of this section, the term "eligible individual" means, with respect to a health insurance issuer that offers health insurance coverage to a small employer in connection with a group health plan in the small group market, such an individual in relation to the employer as shall be determined—
(A) in accordance with the terms of such plan,
(B) as provided by the issuer under rules of the issuer which are uniformly applicable in a State to small employers in the small group market, and
(C) in accordance with all applicable State laws governing such issuer and such market.
(b) Assuring access in large group market
(1) Reports to HHS
The Secretary shall request that the chief executive officer of each State submit to the Secretary, by not later December 31, 2000, and every 3 years thereafter a report on—
(A) the access of large employers to health insurance coverage in the State, and
(B) the circumstances for lack of access (if any) of large employers (or one or more classes of such employers) in the State to such coverage.
(2) Triennial reports to Congress
The Secretary, based on the reports submitted under paragraph (1) and such other information as the Secretary may use, shall prepare and submit to Congress, every 3 years, a report describing the extent to which large employers (and classes of such employers) that seek health insurance coverage in the different States are able to obtain access to such coverage. Such report shall include such recommendations as the Secretary determines to be appropriate.
(3) GAO report on large employer access to health insurance coverage
The Comptroller General shall provide for a study of the extent to which classes of large employers in the different States are able to obtain access to health insurance coverage and the circumstances for lack of access (if any) to such coverage. The Comptroller General shall submit to Congress a report on such study not later than 18 months after August 21, 1996.
(c) Special rules for network plans
(1) In general
In the case of a health insurance issuer that offers health insurance coverage in the small group market through a network plan, the issuer may—
(A) limit the employers that may apply for such coverage to those with eligible individuals who live, work, or reside in the service area for such network plan; and
(B) within the service area of such plan, deny such coverage to such employers if the issuer has demonstrated, if required, to the applicable State authority that—
(i) it will not have the capacity to deliver services adequately to enrollees of any additional groups because of its obligations to existing group contract holders and enrollees, and
(ii) it is applying this paragraph uniformly to all employers without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such employees and dependents.
(2) 180-day suspension upon denial of coverage
An issuer, upon denying health insurance coverage in any service area in accordance with paragraph (1)(B), may not offer coverage in the small group market within such service area for a period of 180 days after the date such coverage is denied.
(d) Application of financial capacity limits
(1) In general
A health insurance issuer may deny health insurance coverage in the small group market if the issuer has demonstrated, if required, to the applicable State authority that—
(A) it does not have the financial reserves necessary to underwrite additional coverage; and
(B) it is applying this paragraph uniformly to all employers in the small group market in the State consistent with applicable State law and without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such employees and dependents.
(2) 180-day suspension upon denial of coverage
A health insurance issuer upon denying health insurance coverage in connection with group health plans in accordance with paragraph (1) in a State may not offer coverage in connection with group health plans in the small group market in the State for a period of 180 days after the date such coverage is denied or until the issuer has demonstrated to the applicable State authority, if required under applicable State law, that the issuer has sufficient financial reserves to underwrite additional coverage, whichever is later. An applicable State authority may provide for the application of this subsection on a service-area-specific basis.
(e) Exception to requirement for failure to meet certain minimum participation or contribution rules
(1) In general
Subsection (a) of this section shall not be construed to preclude a health insurance issuer from establishing employer contribution rules or group participation rules for the offering of health insurance coverage in connection with a group health plan in the small group market, as allowed under applicable State law.
(2) Rules defined
For purposes of paragraph (1)—
(A) the term "employer contribution rule" means a requirement relating to the minimum level or amount of employer contribution toward the premium for enrollment of participants and beneficiaries; and
(B) the term "group participation rule" means a requirement relating to the minimum number of participants or beneficiaries that must be enrolled in relation to a specified percentage or number of eligible individuals or employees of an employer.
(f) Exception for coverage offered only to bona fide association members
Subsection (a) of this section shall not apply to health insurance coverage offered by a health insurance issuer if such coverage is made available in the small group market only through one or more bona fide associations (as defined in
(July 1, 1944, ch. 373, title XXVII, §2711, as added
Prior Provisions
A prior section 2711 of act July 1, 1944, was successively renumbered by subsequent acts and transferred, see
Effective Date
Section applicable with respect to group health plans, and health insurance coverage offered in connection with group health plans, for plan years beginning after June 30, 1997, except as otherwise provided, see section 102(c) of
Section Referred to in Other Sections
This section is referred to in
§300gg–12. Guaranteed renewability of coverage for employers in group market
(a) In general
Except as provided in this section, if a health insurance issuer offers health insurance coverage in the small or large group market in connection with a group health plan, the issuer must renew or continue in force such coverage at the option of the plan sponsor of the plan.
(b) General exceptions
A health insurance issuer may nonrenew or discontinue health insurance coverage offered in connection with a group health plan in the small or large group market based only on one or more of the following:
(1) Nonpayment of premiums
The plan sponsor has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the issuer has not received timely premium payments.
(2) Fraud
The plan sponsor has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.
(3) Violation of participation or contribution rules
The plan sponsor has failed to comply with a material plan provision relating to employer contribution or group participation rules, as permitted under
(4) Termination of coverage
The issuer is ceasing to offer coverage in such market in accordance with subsection (c) of this section and applicable State law.
(5) Movement outside service area
In the case of a health insurance issuer that offers health insurance coverage in the market through a network plan, there is no longer any enrollee in connection with such plan who lives, resides, or works in the service area of the issuer (or in the area for which the issuer is authorized to do business) and, in the case of the small group market, the issuer would deny enrollment with respect to such plan under
(6) Association membership ceases
In the case of health insurance coverage that is made available in the small or large group market (as the case may be) only through one or more bona fide associations, the membership of an employer in the association (on the basis of which the coverage is provided) ceases but only if such coverage is terminated under this paragraph uniformly without regard to any health status-related factor relating to any covered individual.
(c) Requirements for uniform termination of coverage
(1) Particular type of coverage not offered
In any case in which an issuer decides to discontinue offering a particular type of group health insurance coverage offered in the small or large group market, coverage of such type may be discontinued by the issuer in accordance with applicable State law in such market only if—
(A) the issuer provides notice to each plan sponsor provided coverage of this type in such market (and participants and beneficiaries covered under such coverage) of such discontinuation at least 90 days prior to the date of the discontinuation of such coverage;
(B) the issuer offers to each plan sponsor provided coverage of this type in such market, the option to purchase all (or, in the case of the large group market, any) other health insurance coverage currently being offered by the issuer to a group health plan in such market; and
(C) in exercising the option to discontinue coverage of this type and in offering the option of coverage under subparagraph (B), the issuer acts uniformly without regard to the claims experience of those sponsors or any health status-related factor relating to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for such coverage.
(2) Discontinuance of all coverage
(A) In general
In any case in which a health insurance issuer elects to discontinue offering all health insurance coverage in the small group market or the large group market, or both markets, in a State, health insurance coverage may be discontinued by the issuer only in accordance with applicable State law and if—
(i) the issuer provides notice to the applicable State authority and to each plan sponsor (and participants and beneficiaries covered under such coverage) of such discontinuation at least 180 days prior to the date of the discontinuation of such coverage; and
(ii) all health insurance issued or delivered for issuance in the State in such market (or markets) are discontinued and coverage under such health insurance coverage in such market (or markets) is not renewed.
(B) Prohibition on market reentry
In the case of a discontinuation under subparagraph (A) in a market, the issuer may not provide for the issuance of any health insurance coverage in the market and State involved during the 5-year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.
(d) Exception for uniform modification of coverage
At the time of coverage renewal, a health insurance issuer may modify the health insurance coverage for a product offered to a group health plan—
(1) in the large group market; or
(2) in the small group market if, for coverage that is available in such market other than only through one or more bona fide associations, such modification is consistent with State law and effective on a uniform basis among group health plans with that product.
(e) Application to coverage offered only through associations
In applying this section in the case of health insurance coverage that is made available by a health insurance issuer in the small or large group market to employers only through one or more associations, a reference to "plan sponsor" is deemed, with respect to coverage provided to an employer member of the association, to include a reference to such employer.
(July 1, 1944, ch. 373, title XXVII, §2712, as added
Prior Provisions
A prior section 2712 of act July 1, 1944, was successively renumbered by subsequent acts and transferred, see
Effective Date
Section applicable with respect to group health plans, and health insurance coverage offered in connection with group health plans, for plan years beginning after June 30, 1997, except as otherwise provided, see section 102(c) of
Section Referred to in Other Sections
This section is referred to in
§300gg–13. Disclosure of information
(a) Disclosure of information by health plan issuers
In connection with the offering of any health insurance coverage to a small employer, a health insurance issuer—
(1) shall make a reasonable disclosure to such employer, as part of its solicitation and sales materials, of the availability of information described in subsection (b) of this section, and
(2) upon request of such a small employer, provide such information.
(b) Information described
(1) In general
Subject to paragraph (3), with respect to a health insurance issuer offering health insurance coverage to a small employer, information described in this subsection is information concerning—
(A) the provisions of such coverage concerning issuer's right to change premium rates and the factors that may affect changes in premium rates;
(B) the provisions of such coverage relating to renewability of coverage;
(C) the provisions of such coverage relating to any preexisting condition exclusion; and
(D) the benefits and premiums available under all health insurance coverage for which the employer is qualified.
(2) Form of information
Information under this subsection shall be provided to small employers in a manner determined to be understandable by the average small employer, and shall be sufficient to reasonably inform small employers of their rights and obligations under the health insurance coverage.
(3) Exception
An issuer is not required under this section to disclose any information that is proprietary and trade secret information under applicable law.
(July 1, 1944, ch. 373, title XXVII, §2713, as added
Prior Provisions
A prior section 2713 of act July 1, 1944, was successively renumbered by subsequent acts and transferred, see
Effective Date
Section applicable with respect to group health plans, and health insurance coverage offered in connection with group health plans, for plan years beginning after June 30, 1997, except as otherwise provided, see section 102(c) of