42 U.S.C. § 300gg–41 — Guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage

submitted 82 years ago by Pub. L. 104-191 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 1,522 words · no verdicts yet

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This law makes insurers sell individual health coverage to certain people who just lost group coverage. To qualify, you need 18 months of prior coverage and no other insurance options. Insurers can limit which policies they offer, but must follow strict rules for choosing them.

(a) Guaranteed availability. (1) Subject to the rest of this section and to section 300gg–44, an insurer selling individual health coverage in a state generally cannot, for an "eligible individual" (defined in (b)): refuse to offer coverage or deny enrollment to them, or impose any preexisting condition exclusion on their coverage. (2) This requirement doesn't apply in a state that is running an acceptable alternative mechanism under section 300gg–44 instead. (b) "Eligible individual" defined. To qualify, a person must meet all of the following: they have at least 18 months of total creditable coverage as of when they seek this coverage, and their most recent prior coverage was under a group health plan, a government plan, or a church plan; they are not eligible for a group health plan, Medicare Part A or B, or Medicaid, and have no other health insurance; their most recent coverage wasn't ended for nonpayment of premiums or fraud; if they were offered COBRA or a similar state continuation option, they elected it; and if they elected that continuation coverage, they have now used it up. (c) Alternative coverage permitted where there's no state mechanism. (1) In a state without an approved alternative mechanism, an insurer may limit the coverage it must offer under (a), as long as it offers at least two different policy forms — both actively marketed and available to eligible individuals and to others — meeting either (2) or (3) below, as the insurer chooses. Policy forms with different cost-sharing or different riders count as different forms. (2) One way to comply: offer the two individual policy forms with the highest and second-highest premium volume that the insurer sells in that state or market area. (3) The other way: offer a "lower-level" and a "higher-level" coverage form, each similar to the insurer's other individual coverage and each backed by a risk-adjustment, risk-spreading, or subsidization method described in section 300gg–44(c)(3)(A). The lower-level form's actuarial value must be between 85% and 100% of a weighted average described below. The higher-level form's actuarial value must be at least 15 percentage points above the lower-level form's, and between 100% and 120% of that same weighted average. That weighted average is the average actuarial value of all individual coverage the insurer (or, at its choice, all insurers in the state) issued in the individual market the prior year, weighted by enrollment. (4) Whichever approach the insurer picks must apply uniformly to every eligible individual in the state, and must stay in effect for at least 2 years. (5) The actuarial-value calculations in (3) use a standardized population and standardized cost and utilization assumptions. (d) Special rules for network plans. (1) An insurer using a network plan may limit enrollment to people who live, reside, or work in the plan's service area, and may deny coverage within that area if it shows the state authority that it lacks the capacity to serve more enrollees given its existing group and individual obligations — but only if it applies this rule uniformly, regardless of anyone's health status or eligible-individual status. (2) After denying coverage this way in a service area, the insurer can't offer any individual coverage there for 180 days. (e) Application of financial capacity limits. (1) An insurer may deny individual coverage to an eligible individual if it shows the state authority that it lacks the financial reserves to underwrite more coverage, applying this rule uniformly to everyone in the state's individual market regardless of health status or eligible-individual status. (2) After such a denial, the insurer can't offer individual coverage in that service area for 180 days, or until it shows the state it again has sufficient reserves, whichever is later; a state may apply this rule area by area. (e) Market requirements. (The source text labels this subsection "(e)" as well.) (1) Subsection (a) does not force an insurer that only sells coverage through group health plans, or through one or more bona fide associations, to also sell coverage in the individual market. (2) An insurer that sells group coverage doesn't become an individual-market insurer just because it also offers a conversion policy. (f) Construction. Nothing in this section limits the premium rates an insurer may charge under applicable state law, or stops an insurer from offering premium discounts, rebates, or reduced copays/deductibles for participating in health-promotion or disease-prevention programs.

the actual law source: uscode.house.gov ↗public domain

(a) Guaranteed availability

(1) In general

Subject to the succeeding subsections of this section and section 300gg–44 of this title, each health insurance issuer that offers health insurance coverage (as defined in section 300gg–91(b)(1) of this title) in the individual market in a State may not, with respect to an eligible individual (as defined in subsection (b)) desiring to enroll in individual health insurance coverage—

(A)

decline to offer such coverage to, or deny enrollment of, such individual; or

(B)

impose any preexisting condition exclusion (as defined in section 2701(b)(1)(A)) 1 with respect to such coverage.

(2) Substitution by State of acceptable alternative mechanism

The requirement of paragraph (1) shall not apply to health insurance coverage offered in the individual market in a State in which the State is implementing an acceptable alternative mechanism under section 300gg–44 of this title.

(b) “Eligible individual” defined

In this part, the term “eligible individual” means an individual—

(1)

(A)

for whom, as of the date on which the individual seeks coverage under this section, the aggregate of the periods of creditable coverage (as defined in section 2701(c)) ¹ is 18 or more months and (B) whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan (or health insurance coverage offered in connection with any such plan);

(2)

who is not eligible for coverage under (A) a group health plan, (B) part A or part B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.], or (C) a State plan under title XIX of such Act [42 U.S.C. 1396 et seq.] (or any successor program), and does not have other health insurance coverage;

(3)

with respect to whom the most recent coverage within the coverage period described in paragraph (1)(A) was not terminated based on a factor described in paragraph (1) or (2) of section 2712(b) ¹ (relating to nonpayment of premiums or fraud);

(4)

if the individual had been offered the option of continuation coverage under a COBRA continuation provision or under a similar State program, who elected such coverage; and

(5)

who, if the individual elected such continuation coverage, has exhausted such continuation coverage under such provision or program.

(1) In general

In the case of health insurance coverage offered in the individual market in a State in which the State is not implementing an acceptable alternative mechanism under section 300gg–44 of this title, the health insurance issuer may elect to limit the coverage offered under subsection (a) so long as it offers at least two different policy forms of health insurance coverage both of which—

(A)

are designed for, made generally available to, and actively marketed to, and enroll both eligible and other individuals by the issuer; and

(B)

meet the requirement of paragraph (2) or (3), as elected by the issuer.

For purposes of this subsection, policy forms which have different cost-sharing arrangements or different riders shall be considered to be different policy forms.

(2) Choice of most popular policy forms

The requirement of this paragraph is met, for health insurance coverage policy forms offered by an issuer in the individual market, if the issuer offers the policy forms for individual health insurance coverage with the largest, and next to largest, premium volume of all such policy forms offered by the issuer in the State or applicable marketing or service area (as may be prescribed in regulation) by the issuer in the individual market in the period involved.

(3) Choice of 2 policy forms with representative coverage

(A) In general

The requirement of this paragraph is met, for health insurance coverage policy forms offered by an issuer in the individual market, if the issuer offers a lower-level coverage policy form (as defined in subparagraph (B)) and a higher-level coverage policy form (as defined in subparagraph (C)) each of which includes benefits substantially similar to other individual health insurance coverage offered by the issuer in that State and each of which is covered under a method described in section 300gg–44(c)(3)(A) of this title (relating to risk adjustment, risk spreading, or financial subsidization).

(B) Lower-level of coverage described

A policy form is described in this subparagraph if the actuarial value of the benefits under the coverage is at least 85 percent but not greater than 100 percent of a weighted average (described in subparagraph (D)).

A policy form is described in this subparagraph if—

(i)

the actuarial value of the benefits under the coverage is at least 15 percent greater than the actuarial value of the coverage described in subparagraph (B) offered by the issuer in the area involved; and

(ii)

the actuarial value of the benefits under the coverage is at least 100 percent but not greater than 120 percent of a weighted average (described in subparagraph (D)).

(D) Weighted average

For purposes of this paragraph, the weighted average described in this subparagraph is the average actuarial value of the benefits provided by all the health insurance coverage issued (as elected by the issuer) either by that issuer or by all issuers in the State in the individual market during the previous year (not including coverage issued under this section), weighted by enrollment for the different coverage.

(4) Election

The issuer elections under this subsection shall apply uniformly to all eligible individuals in the State for that issuer. Such an election shall be effective for policies offered during a period of not shorter than 2 years.

(5) Assumptions

For purposes of paragraph (3), the actuarial value of benefits provided under individual health insurance coverage shall be calculated based on a standardized population and a set of standardized utilization and cost factors.

(d) Special rules for network plans

(1) In general

In the case of a health insurance issuer that offers health insurance coverage in the individual market through a network plan, the issuer may—

(A)

limit the individuals who may be enrolled under such coverage to those who live, reside, or work within the service area for such network plan; and

(B)

within the service area of such plan, deny such coverage to such individuals 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 additional individual enrollees because of its obligations to existing group contract holders and enrollees and individual enrollees, and

(ii)

it is applying this paragraph uniformly to individuals without regard to any health status-related factor of such individuals and without regard to whether the individuals are eligible individuals.

(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 individual market within such service area for a period of 180 days after such coverage is denied.

(e)2 Application of financial capacity limits

(1) In general

A health insurance issuer may deny health insurance coverage in the individual market to an eligible individual 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 individuals in the individual market in the State consistent with applicable State law and without regard to any health status-related factor of such individuals and without regard to whether the individuals are eligible individuals.

(2) 180-day suspension upon denial of coverage

An issuer upon denying individual health insurance coverage in any service area in accordance with paragraph (1) may not offer such coverage in the individual market within such service area for a period of 180 days after the date such coverage is denied or until the issuer has demonstrated, if required under applicable State law, to the applicable State authority that the issuer has sufficient financial reserves to underwrite additional coverage, whichever is later. A State may provide for the application of this paragraph on a service-area-specific basis.

(e)² Market requirements

(1) In general

The provisions of subsection (a) shall not be construed to require that a health insurance issuer offering health insurance coverage only in connection with group health plans or through one or more bona fide associations, or both, offer such health insurance coverage in the individual market.

(2) Conversion policies

A health insurance issuer offering health insurance coverage in connection with group health plans under this subchapter shall not be deemed to be a health insurance issuer offering individual health insurance coverage solely because such issuer offers a conversion policy.

(f) Construction

Nothing in this section shall be construed—

(1)

to restrict the amount of the premium rates that an issuer may charge an individual for health insurance coverage provided in the individual market under applicable State law; or

(2)

to prevent a health insurance issuer offering health insurance coverage in the individual market from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.

Source credit: (July 1, 1944, ch. 373, title XXVII, § 2741, as added Pub. L. 104–191, title I, § 111(a), Aug. 21, 1996, 110 Stat. 1978.)

history & why it existsrecord from the source credit

1944Enacted · Pub. L. 104-191 · 110 Stat. 1978

A history note hasn’t been published yet. The record shows enactment by Pub. L. 104-191 on 1944-07-01.

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