42 USC 300gg-41 - Guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage

U.S Code last checked for updates: Nov 26, 2024

§ 300gg–41.

Guaranteed availability of individual health insurance coverage to certain individuals with prior group coverage

(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

 See References in Text note below.

with respect to such coverage.

(2)

Substitution by State of acceptable alternative mechanism

(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.

(c)

Alternative coverage permitted where no State mechanism

(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

(3)

Choice of 2 policy forms with representative coverage

(A)

In general

(B)

Lower-level of coverage described

(C)

Higher-level of coverage described

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

(4)

Election

(5)

Assumptions

(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

(e)

 So in original. Two subsecs. (e) have been enacted.

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

(e)

 ² Market requirements

(1)

In general

(2)

Conversion policies

(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.

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

cite as: 42 USC 300gg-41