(a)(1) In this section the following words have the meanings indicated.
(2) “Plan” means, with respect to a product, the pairing of the health benefits under the product with a particular cost-sharing structure, provider network, and service area.
(3)(i) “Product” means a discrete package of health benefits that are offered using a particular product network type within a geographic service area.
(ii) “Product” comprises all plans offered within the product.
(4) “Uniform modification of coverage” means a change to a health benefit plan that meets the criteria stated in 45 C.F.R. § 147.106(e).
Application of percentage point difference upon change in benefits
(b) Changes in benefits made to comply with federal or State requirements are not subject to the plus or minus 2 percentage points referenced in 45 C.F.R. § 147.106(e)(3)(v).
Total service area of product
(c) The combination of all plans offered with a product constitutes the total service area of the product.
Same plan despite modification at time of renewal
(d)(1) With respect to a plan that has been modified at the time of coverage renewal consistent with this section, the plan shall be considered to be the same plan if:
(i) 1. the plan has the same cost-sharing structure as before the modification; or
2. any variation in cost sharing:
A. is solely related to changes in cost or utilization of medical care; or
B. is to maintain the same metal level described in § 1302(d) and (e) of the Affordable Care Act;
(ii) the plan continues to cover a majority of the same service area; and
(iii) the plan continues to cover a majority of the same provider network.
(2) Notwithstanding paragraph (1) of this subsection, the plan shall be considered to be the same plan to the extent that the modifications are:
(i) made uniformly and solely as a result of a federal or State requirement;
(ii) made within a reasonable time period after the imposition or modification of the federal or State requirement; and
(iii) directly related to the imposition or modification of the federal or State requirement.
Renewal of plan
(e) Except as provided in subsection (f) of this section, a carrier shall renew an individual health benefit plan at the option of the eligible individual.
Grounds for cancellation or refusal to renew plan
(f) A carrier may not cancel or refuse to renew an individual health benefit plan except:
(1) for nonpayment of the required premiums;
(2) where the individual has performed an act or practice that constitutes fraud;
(3) where the individual has made an intentional misrepresentation of material fact under the terms of the coverage;
(4) where the carrier elects not to renew all of its individual health benefit plans in the State in accordance with this article;
(5) where the individual no longer resides, lives, or works in the service area, provided that:
(i) the coverage is terminated under this provision uniformly without regard to any health status-related factor of covered individuals; and
(ii) notice of the termination is provided to the individual at least 90 calendar days before the date coverage will be terminated; or
(6) for individual health benefit plans that are not grandfathered health plans, as defined in 45 C.F.R. § 147.140, where a carrier discontinues offering a particular product in the individual market, if the carrier:
(i) at least 90 days before discontinuation of the product, provides notice of the discontinuation to each individual provided coverage under the product;
(ii) offers each individual provided coverage under the product the option to purchase any other individual health benefit plan coverage offered by the carrier for individuals in the State; and
(iii) acts uniformly without regard to any health status-related factor of enrolled individuals or individuals who may become eligible for the coverage.
Uniform modification of coverage
(g) A carrier may make a uniform modification of coverage for a product only at the time of renewal of the health benefit plan.
Notice of renewal or uniform modification of coverage
(h) A carrier shall provide notice of renewal or uniform modification of coverage for:
(1) grandfathered health plan coverage, at least 60 days before the date the coverage will be renewed; and
(2) a health benefit plan that is not grandfathered health plan coverage, before the date of the first day of the next annual open enrollment period, in a form and manner specified by the Secretary of Health and Human Services.
Cancellation or refusal to renew an individual health benefit plan
(i) A carrier may not cancel or refuse to renew an individual health benefit plan because an eligible individual is entitled to or enrolled in Medicare if the eligible individual is renewing coverage under the same policy or contract of insurance.
Credits
Added by Acts 1997, c. 294, § 3, eff. Oct. 1, 1997; Amended by Acts 2002, c. 153, § 5, eff. July 1, 2003; Acts 2002, c. 247, § 1, eff. June 1, 2002. Amended by Acts 2013, c. 368, § 2, eff. Jan. 1, 2014; Acts 2015, c. 363, § 1, eff. May 12, 2015; Acts 2017, c. 720, § 1, eff. June 1, 2017; Acts 2018, c. 12, § 1, eff. April 5, 2018; Acts 2018, c. 665, § 1, eff. Oct. 1, 2018.
Current through legislation effective through April 9, 2023, from the 2024 Regular Session of the General Assembly. Some statute sections may be more current, see credits for details.
