2013 -- S 0201 SUBSTITUTE A

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LC00740/SUB A

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2013

____________

A N A C T

RELATING TO INSURANCE -- GENDER RATING

     Introduced By: Senators Sosnowski, Miller, Nesselbush, Cool Rumsey, and Gallo

     Date Introduced: February 06, 2013

     Referred To: Senate Health & Human Services

It is enacted by the General Assembly as follows:

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     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness

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Insurance Policies" is hereby amended by adding thereto the following section:

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     27-18-79. Gender rating. – (a) Effective January 1, 2014, no individual or small group

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health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state,

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which provides medical coverage that includes coverage for physician services in a physician’s

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office, and no policy which provides major medical and/or similar comprehensive-type coverage,

1-7

excluding policies listed in (c), shall vary the premium rate for a health coverage plan based on

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the gender of the individual policy holders, enrollees, subscribers, or members.

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     (b) Effective April 1, 2015, no large group health insurance employer contract, plan, or

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policy delivered, issued for delivery, or renewed in this state, which provides medical coverage

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that includes coverage for physician services in a physician’s office and any policy which

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provides major medical and/or similar comprehensive-type coverage, excluding policies listed in

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(c), shall vary the premium rate based on the gender of the individual policy holders, enrollees,

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subscribers, or members in any one age group.

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     (c) This section shall not apply to insurance coverage providing benefits for any of the

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following:

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     (1) Hospital confinement indemnity;

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     (2) Disability income;

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     (3) Accident only;

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     (4) Long-term care;

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     (5) Medicare supplement;

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     (6) Limited benefit health;

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     (7) Specified diseased indemnity;

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     (8) Sickness of bodily injury or death by accident or both;

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     (9) Other limited benefit policies.

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     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

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Corporations" is hereby amended by adding thereto the following section:

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     27-19-70. Gender rating. -- (a) Effective January 1, 2014, no individual or small group

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health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state,

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which provides medical coverage that includes coverage for physician services in a physician’s

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office, and no policy which provides major medical and/or similar comprehensive-type coverage,

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excluding policies listed in (c), shall vary the premium rate for a health coverage plan based on

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the gender of the individual policy holders, enrollees, subscribers, or members.

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     (b) Effective April 1, 2015, no large group health insurance employer contract, plan, or

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policy delivered, issued for delivery, or renewed in this state, which provides medical coverage

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that includes coverage for physician services in a physician’s office and any policy which

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provides major medical and/or similar comprehensive-type coverage, excluding policies listed in

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(c), shall vary the premium rate based on the gender of the individual policy holders, enrollees,

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subscribers, or members in any one age group.

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     (c) This section shall not apply to insurance coverage providing benefits for any of the

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following:

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     (1) Hospital confinement indemnity;

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     (2) Disability income;

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     (3) Accident only;

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     (4) Long-term care;

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     (5) Medicare supplement;

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     (6) Limited benefit health;

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     (7) Specified diseased indemnity;

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     (8) Sickness of bodily injury or death by accident or both;

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     (9) Other limited benefit policies.

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     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

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Corporations" is hereby amended by adding thereto the following section:

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     27-20-65. Gender rating. -- (a) Effective January 1, 2014, no individual or small group

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health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state,

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which provides medical coverage that includes coverage for physician services in a physician’s

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office, and no policy which provides major medical and/or similar comprehensive-type coverage,

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excluding policies listed in (c), shall vary the premium rate for a health coverage plan based on

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the gender of the individual policy holders, enrollees, subscribers, or members.

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     (b) Effective April 1, 2015, no large group health insurance employer contract, plan, or

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policy delivered, issued for delivery, or renewed in this state, which provides medical coverage

3-7

that includes coverage for physician services in a physician’s office and any policy which

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provides major medical and/or similar comprehensive-type coverage, excluding policies listed in

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(c), shall vary the premium rate based on the gender of the individual policy holders, enrollees,

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subscribers, or members in any one age group.

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     (c) This section shall not apply to insurance coverage providing benefits for any of the

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     following:

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     (1) Hospital confinement indemnity;

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     (2) Disability income;

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     (3) Accident only;

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     (4) Long-term care;

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     (5) Medicare supplement;

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     (6) Limited benefit health;

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     (7) Specified diseased indemnity;

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     (8) Sickness of bodily injury or death by accident 1 or both;

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     (9) Other limited benefit policies.

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     SECTION 4. Chapter 27-41 of the General Laws entitled "Health Maintenance

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Organizations" is hereby amended by adding thereto the following section:

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     27-41-83. Gender rating. -- (a) Effective January 1, 2014, no individual or small group

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health insurance contract, plan, or policy delivered, issued for delivery, or renewed in this state,

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which provides medical coverage that includes coverage for physician services in a physician’s

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office, and no policy which provides major medical and/or similar comprehensive-type coverage,

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excluding policies listed in (c), shall vary the premium rate for a health coverage plan based on

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the gender of the individual policy holders, enrollees, subscribers, or members.

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     (b) Effective April 1, 2015, no large group health insurance employer contract, plan, or

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policy delivered, issued for delivery, or renewed in this state, which provides medical coverage

3-32

that includes coverage for physician services in a physician’s office and any policy which

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provides major medical and/or similar comprehensive-type coverage, excluding policies listed in

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(c), shall vary the premium rate based on the gender of the individual policy holders, enrollees,

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subscribers, or members in any one age group.

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     (c) This section shall not apply to insurance coverage providing benefits for any of the

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     following:

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     (1) Hospital confinement indemnity;

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     (2) Disability income;

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     (3) Accident only;

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     (4) Long-term care;

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     (5) Medicare supplement;

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     (6) Limited benefit health;

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     (7) Specified diseased indemnity;

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     (8) Sickness of bodily injury or death by accident or both;

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     (9) Other limited benefit policies.

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     SECTION 5. Section 27-50-5 of the General Laws in Chapter 27-50 entitled "Small

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Employer Health Insurance Availability Act" is hereby amended to read as follows:

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     27-50-5. Restrictions relating to premium rates. -- (a) Premium rates for health plans

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subject to this chapter are subject to the following provisions:

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     (1) Subject to subdivision (2) of this subsection, a small employer carrier shall develop

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     its rates based on an adjusted community rate and may only vary the adjusted community

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rate for:

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     (i) Age; and

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     (ii) Gender in accordance with sections 27-41-83, 27-20-65. 27-19-70, 27-18-79; and

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     (iii) Family composition;

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     (2) The adjustment for age in paragraph (1)(i) of this subsection may not use age

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     brackets smaller than five (5) year increments and these shall begin with age thirty (30)

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and end with age sixty-five (65).

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      (3) The small employer carriers are permitted to develop separate rates for individuals

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     age sixty-five (65) or older for coverage for which Medicare is the primary payer and

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coverage for which Medicare is not the primary payer. Both rates are subject to the requirements

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of this subsection.

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     (4) For each health benefit plan offered by a carrier, the highest premium rate for each

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family composition type shall not exceed four (4) times the premium rate that could be charged to

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a small employer with the lowest premium rate for that family composition.

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     (5) Premium rates for bona fide associations except for the Rhode Island Builders'

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Association whose membership is limited to those who are actively involved in supporting the

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construction industry in Rhode Island shall comply with the requirements of section 27-50-5.

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     (6) For a small employer group renewing its health insurance with the same small

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employer carrier which provided it small employer health insurance in the prior year, the

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combined adjustment factor for age and gender for that small employer group will not exceed one

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hundred twenty percent (120%) of the combined adjustment factor for age and gender for that

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small employer group in the prior rate year.

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     (b) The premium charged for a health benefit plan may not be adjusted more frequently

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than annually except that the rates may be changed to reflect:

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     (1) Changes to the enrollment of the small employer;

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     (2) Changes to the family composition of the employee; or

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     (3) Changes to the health benefit plan requested by the small employer.

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     (c) Premium rates for health benefit plans shall comply with the requirements of this

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section.

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     (d) Small employer carriers shall apply rating factors consistently with respect to all

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small employers. Rating factors shall produce premiums for identical groups that differ only by

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the amounts attributable to plan design and do not reflect differences due to the nature of the

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groups assumed to select particular health benefit plans. Two groups that are otherwise identical,

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but which have different prior year rate factors may, however, have rating factors that produce

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premiums that differ because of the requirements of subdivision 27-50-5(a)(6). Nothing in this

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section shall be construed to prevent a group health plan and a health insurance carrier offering

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health insurance coverage from establishing premium discounts or rebates or modifying

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otherwise applicable copayments or deductibles in return for adherence to programs of health

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promotion and disease prevention, including those included in affordable health benefit plans,

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provided that the resulting rates comply with the other requirements of this section, including

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subdivision (a)(5) of this section.

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     The calculation of premium discounts, rebates, or modifications to otherwise applicable

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copayments or deductibles for affordable health benefit plans shall be made in a manner

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consistent with accepted actuarial standards and based on actual or reasonably anticipated small

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employer claims experience. As used in the preceding sentence, "accepted actuarial standards"

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includes actuarially appropriate use of relevant data from outside the claims experience of small

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employers covered by affordable health plans, including, but not limited to, experience derived

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from the large group market, as this term is defined in section 27-18.6-2(19).

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      (e) For the purposes of this section, a health benefit plan that contains a restricted

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network provision shall not be considered similar coverage to a health benefit plan that does not

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contain such a provision, provided that the restriction of benefits to network providers results in

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substantial differences in claim costs.

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      (f) The health insurance commissioner may establish regulations to implement the

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provisions of this section and to assure that rating practices used by small employer carriers are

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consistent with the purposes of this chapter, including regulations that assure that differences in

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rates charged for health benefit plans by small employer carriers are reasonable and reflect

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objective differences in plan design or coverage (not including differences due to the nature of the

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groups assumed to select particular health benefit plans or separate claim experience for

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individual health benefit plans) and to ensure that small employer groups with one eligible

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subscriber are notified of rates for health benefit plans in the individual market.

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     (g) In connection with the offering for sale of any health benefit plan to a small employer,

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a small employer carrier shall make a reasonable disclosure, as part of its solicitation and sales

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materials, of all of the following:

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     (1) The provisions of the health benefit plan concerning the small employer carrier's right

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to change premium rates and the factors, other than claim experience, that affect changes

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premium rates;

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     (2) The provisions relating to renewability of policies and contracts;

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     (3) The provisions relating to any preexisting condition provision; and

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     (4) A listing of and descriptive information, including benefits and premiums, about all

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     benefit plans for which the small employer is qualified.

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     (h) (1) Each small employer carrier shall maintain at its principal place of business a

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complete and detailed description of its rating practices and renewal underwriting practices,

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including information and documentation that demonstrate that its rating methods and practices

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are based upon commonly accepted actuarial assumptions and are in accordance with sound

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actuarial principles.

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      (2) Each small employer carrier shall file with the commissioner annually on or before

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March 15 an actuarial certification certifying that the carrier is in compliance with this chapter

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and that the rating methods of the small employer carrier are actuarially sound. The certification

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shall be in a form and manner, and shall contain the information, specified by the commissioner.

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A copy of the certification shall be retained by the small employer carrier at its principal place of

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business.

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      (3) A small employer carrier shall make the information and documentation described in

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subdivision (1) of this subsection available to the commissioner upon request. Except in cases of

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violations of this chapter, the information shall be considered proprietary and trade secret

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information and shall not be subject to disclosure by the director to persons outside of the

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department except as agreed to by the small employer carrier or as ordered by a court of

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competent jurisdiction.

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     (4) For the wellness health benefit plan described in section 27-50-10, the rates proposed

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to be charged and the plan design to be offered by any carrier shall be filed by the carrier at the

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office of the commissioner no less than thirty (30) days prior to their proposed date of use. The

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carrier shall be required to establish that the rates proposed to be charged and the plan design to

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be offered are consistent with the proper conduct of its business and with the interest of the

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public. The commissioner may approve, disapprove, or modify the rates and/or approve or

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disapprove the plan design proposed to be offered by the carrier. Any disapproval by the

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commissioner of a plan design proposed to be offered shall be based upon a determination that

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the plan design is not consistent with the criteria established pursuant to subsection 27-50- (b).

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     (i) The requirements of this section apply to all health benefit plans issued or renewed on

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or after October 1, 2000.

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     SECTION 6. Sections 27-20-27, 27-20-27.1, 27-20-27.2 and 27-20-27.3 of the General

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Laws in Chapter 27-20 entitled "Nonprofit Medical Service Corporations" are hereby amended to

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read as follows:

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     27-20-27. New cancer therapies – Under investigation. [Repealed on effective date of

7-19

section 27-20-64]. -- New cancer therapies – Under investigation. [Repealed on effective date

7-20

of section 27-20-60]. -- Every individual or group hospital or medical expense insurance policy

7-21

or individual or group hospital or medical service plan contract delivered, issued for delivery or

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renewed in this state shall provide coverage for new cancer therapies still under investigation as

7-23

outlined in this chapter.

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     27-20-27.1."Reliable evidence" defined. [Repealed on effective date of section 27-

7-25

20-64]. -- "Reliable evidence" defined. [Repealed on effective date of section 27-20-60]. --

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     "Reliable evidence" means:

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     (1) Evidence including published reports and articles in authoritative, peer reviewed

7-28

medical and scientific literature;

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     (2) A written informed consent used by the treating facility or by another facility studying

7-30

substantially the same service; or

7-31

     (3) A written protocol or protocols used by the treating facility or protocols of another

7-32

facility studying substantially the same service.

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      27-20-27.2. Conditions of coverage. [Repealed on effective date of section 27-20-

7-34

64.]. -- Conditions of coverage. [Repealed on effective date of section 27-20-60.]. --As

8-1

provided in § 27-20-27, coverage shall be extended to new cancer therapies still under

8-2

investigation when the following circumstances are present:

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     (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

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been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

8-5

Institute (NCI), community clinical oncology programs; the Food and Drug Administration in the

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form of an investigational new drug (IND) exemption; the Department of Veterans' Affairs; or a

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qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

8-8

support grants;

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     (2) The proposed therapy has been reviewed and approved by a qualified institutional

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review board (IRB);

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     (3) The facility and personnel providing the treatment are capable of doing so by virtue of

8-12

their experience, training, and volume of patients treated to maintain expertise;

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     (4) The patients receiving the investigational treatment meet all protocol requirements;

8-14

     (5) There is no clearly superior, noninvestigational alternative to the protocol treatment;

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     (6) The available clinical or preclinical data provide a reasonable expectation that the

8-16

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

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     (7) The coverage of new cancer therapy treatment provided pursuant to a phase II clinical

8-18

trial is not required for only that portion of that treatment that is provided as part of the phase II

8-19

clinical trial and is funded by a national agency, such as the National Cancer Institute, the

8-20

Veteran's Administration, the Department of Defense, or funded by commercial organizations

8-21

such as the biotechnical and/or pharmaceutical industry or manufacturers of medical devices. Any

8-22

portions of a phase II trial which are customarily funded by government, biotechnical and/or

8-23

pharmaceutical and/or medical device industry sources in Rhode Island or in other states shall

8-24

continue to be funded in Rhode Island and coverage pursuant to this section supplements, does

8-25

not supplant customary funding.

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     27-20-27.3. Managed care. [Repealed on effective date of section 27-20-64.]. --

8-27

Managed care. [Repealed on effective date of section 27-20-60.]. -- Nothing in this chapter

8-28

shall preclude the conducting of managed care reviews and medical necessity reviews by an

8-29

insurer, hospital or medical service corporation, or health maintenance organization. A nonprofit

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medical service corporation may, as a condition of coverage, require its members to obtain new

8-31

cancer therapies still under investigation as outlined in this chapter from providers and facilities

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designated by the nonprofit medical service corporation to render these new cancer therapies.

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     SECTION 7. Sections 27-18-36, 27-18-36.1, 27-18-36.2 and 27-18-36.3 of the General

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Laws in Chapter 27-18 entitled "Accident and Sickness Insurance Policies" are hereby amended

9-1

to read as follows:

9-2

     27-18-36. New cancer therapies – Under investigation. [Repealed on effective date of

9-3

section 27-18-80.]. -- New cancer therapies – Under investigation. [Repealed on effective

9-4

date of section 27-18-74.]. --Every individual or group hospital or medical expense insurance

9-5

policy or individual or group hospital or medical service plan contract delivered, issued for

9-6

delivery or renewed in this state, except policies which only provide coverage for specified

9-7

diseases other than cancer, fixed indemnity, disability income, accident only, long-term care

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Medicare supplement limited benefit health, sickness or bodily injury or death by accident or

9-9

both, or other limited benefit policies, shall provide coverage for new cancer therapies still under

9-10

investigation as outlined in this chapter.

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     27-18-36.1."Reliable evidence" defined. [Repealed on effective date of section 27-18-

9-12

80.]. -- "Reliable evidence" defined. [Repealed on effective date of section 27-18-74.]. --

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"Reliable evidence" means:

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     (1) Evidence including published reports and articles in authoritative, peer reviewed

9-15

medical and scientific literature;

9-16

     (2) A written informed consent used by the treating facility or by another facility studying

9-17

substantially the same service; or

9-18

     (3) A written protocol or protocols used by the treating facility or protocols of another

9-19

facility studying substantially the same service.

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     27-18-36.2. Conditions of coverage. [Repealed on effective date of section 27-18-80.].

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-- Conditions of coverage. [Repealed on effective date of section 27-18-74.]. --As provided in

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§ 27-18-36, coverage shall be extended to new cancer therapies still under investigation when the

9-23

following circumstances are present:

9-24

     (1) Treatment is being provided pursuant to a phase II, III or IV clinical trial which has

9-25

been approved by the National Institutes of Health (NIH) in cooperation with the National Cancer

9-26

Institute (NCI), Community clinical oncology programs; the Food and Drug Administration in the

9-27

form of an Investigational New Drug (IND) exemption; the Department of Veterans' Affairs; or a

9-28

qualified nongovernmental research entity as identified in the guidelines for NCI cancer center

9-29

support grants;

9-30

     (2) The proposed therapy has been reviewed and approved by a qualified institutional

9-31

review board (IRB);

9-32

     (3) The facility and personnel providing the treatment are capable of doing so by virtue of

9-33

their experience, training, and volume of patients treated to maintain expertise;

10-34

     (4) The patients receiving the investigational treatment meet all protocol requirements;

10-35

     (5) There is no clearly superior, noninvestigational alternative to the protocol treatment;

10-36

     (6) The available clinical or preclinical data provide a reasonable expectation that the

10-37

protocol treatment will be at least as efficacious as the noninvestigational alternative; and

10-38

     (7) The coverage of new cancer therapy treatment provided pursuant to a Phase II clinical

10-39

trial shall not be required for only that portion of that treatment provided as part of the phase II

10-40

clinical trial and is otherwise funded by a national agency, such as the National Cancer Institute,

10-41

the Veteran's Administration, the Department of Defense, or funded by commercial organizations

10-42

such as the biotechnical and/or pharmaceutical industry or manufacturers of medical devices. Any

10-43

portions of a Phase II trial which are customarily funded by government, biotechnical and/or

10-44

pharmaceutical and/or medical device industry sources in Rhode Island or in other states shall

10-45

continue to be so funded in Rhode Island and coverage pursuant to this section shall supplement,

10-46

not supplant, customary funding.

10-47

     27-18-36.3. Managed care. [Repealed on effective date of section 27-18-80.] --

10-48

Managed care. [Repealed on effective date of section 27-18-74.] --Nothing in this chapter

10-49

shall preclude the conducting of managed care reviews and medical necessity reviews by an

10-50

insurer, hospital or medical service corporation, or health maintenance organization.

10-51

     SECTION 8. Section 27-18-71 of the General Laws in Chapter 27-18 entitled "Accident

10-52

and Sickness Insurance Policies" are hereby amended to read as follows:

10-53

     27-18-71. Prohibition on preexisting condition exclusions. -- (a) A health insurance

10-54

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

10-55

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

10-56

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

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imposing a preexisting condition exclusion on that individual.

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     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

10-59

exclude coverage for any individual by imposing a preexisting condition exclusion on that

10-60

individual.

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     (b) As used in this section:

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     (1) "Preexisting condition exclusion" means a limitation or exclusion of benefits,

10-63

including a denial of coverage, based on the fact that the condition (whether physical or mental)

10-64

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

10-65

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

10-66

recommended or received before the effective date of coverage.

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      (2) "Preexisting condition exclusion" means any limitation or exclusion of benefits,

10-68

including a denial of coverage, applicable to an individual as a result of information relating to an

11-1

individual's health status before the individual's effective date of coverage, or if the coverage is

11-2

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

11-3

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

11-4

the individual, or review of medical records relating to the pre-enrollment period.

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     "Preexisting condition exclusion" means: with respect to coverage, a limitation or

11-6

exclusion of benefits relating to a condition based on the fact that the condition was present

11-7

before the date of enrollment for such coverage, whether or not any medical advice, diagnosis,

11-8

care, or treatment was recommended or received before such date.

11-9

     (c) This section shall not apply to grandfathered health plans providing individual health

11-10

insurance coverage.

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     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

11-12

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

11-13

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

11-14

bodily injury or death by accident or both; and (9) Other limited benefit policies.

11-15

     SECTION 9. Section 27-18.5-10 of the General Laws in Chapter 27-18.5 entitled

11-16

"Individual Health Insurance Coverage" are hereby amended to read as follows:

11-17

     27-18.5-10. Prohibition on preexisting condition exclusions. -- (a) A health insurance

11-18

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

11-19

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

11-20

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

11-21

imposing a preexisting condition exclusion on that individual.

11-22

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

11-23

exclude coverage for any individual by imposing a preexisting condition exclusion on that

11-24

individual.

11-25

     (b) As used in this section:

11-26

     (1) "Preexisting condition exclusion" means a limitation or exclusion of benefits,

11-27

including a denial of coverage, based on the fact that the condition (whether physical or mental)

11-28

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

11-29

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

11-30

recommended or received before the effective date of coverage.

11-31

      (2) "Preexisting condition exclusion" means any limitation or exclusion of benefits,

11-32

including a denial of coverage, applicable to an individual as a result of information relating to an

11-33

individual's health status before the individual's effective date of coverage, or if the coverage is

11-34

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

12-1

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

12-2

the individual, or review of medical records relating to the pre-enrollment period.

12-3

     "Preexisting condition exclusion" means: with respect to coverage, a limitation or

12-4

exclusion of benefits relating to a condition based on the fact that the condition was present

12-5

before the date of enrollment for such coverage, whether or not any medical advice, diagnosis,

12-6

care, or treatment was recommended or received before such date.

12-7

     (c) This section shall not apply to grandfathered health plans providing individual health

12-8

insurance coverage.

12-9

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

12-10

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

12-11

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

12-12

bodily injury or death by accident or both; and (9) Other limited benefit policies.

12-13

     SECTION 10. Section 27-19-68 of the General Laws in Chapter 27-19 entitled

12-14

"Nonprofit Hospital Service Corporations" are hereby amended to read as follows:

12-15

     27-19-68. Prohibition preexisting condition exclusions. -- (a) A health insurance

12-16

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

12-17

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

12-18

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

12-19

imposing a preexisting condition exclusion on that individual.

12-20

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

12-21

exclude coverage for any individual by imposing a preexisting condition exclusion on that

12-22

individual.

12-23

     (b) As used in this section:

12-24

     (1) "Preexisting condition exclusion" means a limitation or exclusion of benefits,

12-25

including a denial of coverage, based on the fact that the condition (whether physical or mental)

12-26

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

12-27

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

12-28

recommended or received before the effective date of coverage.

12-29

      (2) "Preexisting condition exclusion" means any limitation or exclusion of benefits,

12-30

including a denial of coverage, applicable to an individual as a result of information relating to an

12-31

individual's health status before the individual's effective date of coverage, or if the coverage is

12-32

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

12-33

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

12-34

the individual, or review of medical records relating to the pre-enrollment period.

13-1

     "Preexisting condition exclusion" means: with respect to coverage, a limitation or

13-2

exclusion of benefits relating to a condition based on the fact that the condition was present

13-3

before the date of enrollment for such coverage, whether or not any medical advice, diagnosis,

13-4

care, or treatment was recommended or received before such date.

13-5

     (c) This section shall not apply to grandfathered health plans providing individual health

13-6

insurance coverage.

13-7

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

13-8

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

13-9

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

13-10

bodily injury or death by accident or both; and (9) Other limited benefit policies.

13-11

     SECTION 11. Section 27-20-57 of the General Laws in Chapter 27-20 entitled

13-12

"Nonprofit Medical Service Corporations" are hereby amended to read as follows:

13-13

     27-20-57. Prohibition preexisting condition exclusions. -- (a) A health insurance

13-14

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

13-15

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

13-16

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

13-17

imposing a preexisting condition exclusion on that individual.

13-18

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

13-19

exclude coverage for any individual by imposing a preexisting condition exclusion on that

13-20

individual.

13-21

     (b) As used in this section:

13-22

     (1) "Preexisting condition exclusion" means a limitation or exclusion of benefits,

13-23

including a denial of coverage, based on the fact that the condition (whether physical or mental)

13-24

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

13-25

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

13-26

recommended or received before the effective date of coverage.

13-27

      (2) "Preexisting condition exclusion" means any limitation or exclusion of benefits,

13-28

including a denial of coverage, applicable to an individual as a result of information relating to an

13-29

individual's health status before the individual's effective date of coverage, or if the coverage is

13-30

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

13-31

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

13-32

the individual, or review of medical records relating to the pre-enrollment period.

13-33

     "Preexisting condition exclusion" means: with respect to coverage, a limitation or

13-34

exclusion of benefits relating to a condition based on the fact that the condition was present

14-1

before the date of enrollment for such coverage, whether or not any medical advice, diagnosis,

14-2

care, or treatment was recommended or received before such date.

14-3

     (c) This section shall not apply to grandfathered health plans providing individual health

14-4

insurance coverage.

14-5

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

14-6

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

14-7

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

14-8

bodily injury or death by accident or both; and (9) Other limited benefit policies.

14-9

     SECTION 12. Section 27-41-81 of the General Laws in Chapter 27-41 entitled "Health

14-10

Maintenance Organizations" are hereby amended to read as follows:

14-11

     27-41-81. Prohibition preexisting condition exclusions. -- (a) A health insurance

14-12

policy, subscriber contract, or health plan offered, issued, issued for delivery, or issued to cover a

14-13

resident of this state by a health insurance company licensed pursuant to this title and/or chapter:

14-14

     (1) Shall not limit or exclude coverage for an individual under the age of nineteen (19) by

14-15

imposing a preexisting condition exclusion on that individual.

14-16

     (2) For plan or policy years beginning on or after January 1, 2014, shall not limit or

14-17

exclude coverage for any individual by imposing a preexisting condition exclusion on that

14-18

individual.

14-19

     (b) As used in this section:

14-20

     (1) "Preexisting condition exclusion" means a limitation or exclusion of benefits,

14-21

including a denial of coverage, based on the fact that the condition (whether physical or mental)

14-22

was present before the effective date of coverage, or if the coverage is denied, the date of denial,

14-23

under a health benefit plan whether or not any medical advice, diagnosis, care or treatment was

14-24

recommended or received before the effective date of coverage.

14-25

      (2) "Preexisting condition exclusion" means any limitation or exclusion of benefits,

14-26

including a denial of coverage, applicable to an individual as a result of information relating to an

14-27

individual's health status before the individual's effective date of coverage, or if the coverage is

14-28

denied, the date of denial, under the health benefit plan, such as a condition (whether physical or

14-29

mental) identified as a result of a pre-enrollment questionnaire or physical examination given to

14-30

the individual, or review of medical records relating to the pre-enrollment period.

14-31

     "Preexisting condition exclusion" means: with respect to coverage, a limitation or

14-32

exclusion of benefits relating to a condition based on the fact that the condition was present

14-33

before the date of enrollment for such coverage, whether or not any medical advice, diagnosis,

14-34

care, or treatment was recommended or received before such date.

15-1

     (c) This section shall not apply to grandfathered health plans providing individual health

15-2

insurance coverage.

15-3

     (d) This section shall not apply to insurance coverage providing benefits for: (1) Hospital

15-4

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

15-5

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

15-6

bodily injury or death by accident or both; and (9) Other limited benefit policies.

15-7

     SECTION 13. Sections 27-50-3 and 27-50-7 of the General Laws in Chapter 27-50

15-8

entitled "Small Employer Health Insurance Availability Act" are hereby amended to read as

15-9

follows:

15-10

     27-50-3. Definitions. [Effective December 31, 2010.]. -- (a) "Actuarial certification"

15-11

means a written statement signed by a member of the American Academy of Actuaries or other

15-12

individual acceptable to the director that a small employer carrier is in compliance with the

15-13

provisions of section 27-50-5, based upon the person's examination and including a review of the

15-14

appropriate records and the actuarial assumptions and methods used by the small employer carrier

15-15

in establishing premium rates for applicable health benefit plans.

15-16

      (b) "Adjusted community rating" means a method used to develop a carrier's premium

15-17

which spreads financial risk across the carrier's entire small group population in accordance with

15-18

the requirements in section 27-50-5.

15-19

      (c) "Affiliate" or "affiliated" means any entity or person who directly or indirectly

15-20

through one or more intermediaries controls or is controlled by, or is under common control with,

15-21

a specified entity or person.

15-22

      (d) "Affiliation period" means a period of time that must expire before health insurance

15-23

coverage provided by a carrier becomes effective, and during which the carrier is not required to

15-24

provide benefits.

15-25

      (e) "Bona fide association" means, with respect to health benefit plans offered in this

15-26

state, an association which:

15-27

      (1) Has been actively in existence for at least five (5) years;

15-28

      (2) Has been formed and maintained in good faith for purposes other than obtaining

15-29

insurance;

15-30

      (3) Does not condition membership in the association on any health-status related factor

15-31

relating to an individual (including an employee of an employer or a dependent of an employee);

15-32

      (4) Makes health insurance coverage offered through the association available to all

15-33

members regardless of any health status-related factor relating to those members (or individuals

15-34

eligible for coverage through a member);

16-1

      (5) Does not make health insurance coverage offered through the association available

16-2

other than in connection with a member of the association;

16-3

      (6) Is composed of persons having a common interest or calling;

16-4

      (7) Has a constitution and bylaws; and

16-5

      (8) Meets any additional requirements that the director may prescribe by regulation.

16-6

      (f) "Carrier" or "small employer carrier" means all entities licensed, or required to be

16-7

licensed, in this state that offer health benefit plans covering eligible employees of one or more

16-8

small employers pursuant to this chapter. For the purposes of this chapter, carrier includes an

16-9

insurance company, a nonprofit hospital or medical service corporation, a fraternal benefit

16-10

society, a health maintenance organization as defined in chapter 41 of this title or as defined in

16-11

chapter 62 of title 42, or any other entity subject to state insurance regulation that provides

16-12

medical care as defined in subsection (y) that is paid or financed for a small employer by such

16-13

entity on the basis of a periodic premium, paid directly or through an association, trust, or other

16-14

intermediary, and issued, renewed, or delivered within or without Rhode Island to a small

16-15

employer pursuant to the laws of this or any other jurisdiction, including a certificate issued to an

16-16

eligible employee which evidences coverage under a policy or contract issued to a trust or

16-17

association.

16-18

      (g) "Church plan" has the meaning given this term under section 3(33) of the Employee

16-19

Retirement Income Security Act of 1974 [29 U.S.C. section 1002(33)_.

16-20

      (h) "Control" is defined in the same manner as in chapter 35 of this title.

16-21

      (i) (1) "Creditable coverage" means, with respect to an individual, health benefits or

16-22

coverage provided under any of the following:

16-23

      (i) A group health plan;

16-24

      (ii) A health benefit plan;

16-25

      (iii) Part A or part B of Title XVIII of the Social Security Act, 42 U.S.C. section 1395c

16-26

et seq., or 42 U.S.C. section 1395j et seq., (Medicare);

16-27

      (iv) Title XIX of the Social Security Act, 42 U.S.C. section 1396 et seq., (Medicaid),

16-28

other than coverage consisting solely of benefits under 42 U.S.C. section 1396s (the program for

16-29

distribution of pediatric vaccines);

16-30

      (v) 10 U.S.C. section 1071 et seq., (medical and dental care for members and certain

16-31

former members of the uniformed services, and for their dependents)(Civilian Health and

16-32

Medical Program of the Uniformed Services)(CHAMPUS). For purposes of 10 U.S.C. section

16-33

1071 et seq., "uniformed services" means the armed forces and the commissioned corps of the

16-34

National Oceanic and Atmospheric Administration and of the Public Health Service;

17-1

      (vi) A medical care program of the Indian Health Service or of a tribal organization;

17-2

      (vii) A state health benefits risk pool;

17-3

      (viii) A health plan offered under 5 U.S.C. section 8901 et seq., (Federal Employees

17-4

Health Benefits Program (FEHBP));

17-5

      (ix) A public health plan, which for purposes of this chapter, means a plan established or

17-6

maintained by a state, county, or other political subdivision of a state that provides health

17-7

insurance coverage to individuals enrolled in the plan; or

17-8

      (x) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. section

17-9

2504(e)).

17-10

      (2) A period of creditable coverage shall not be counted, with respect to enrollment of an

17-11

individual under a group health plan, if, after the period and before the enrollment date, the

17-12

individual experiences a significant break in coverage.

17-13

      (j) "Dependent" means a spouse, child under the age twenty-six (26) years, and an

17-14

unmarried child of any age who is financially dependent upon, the parent and is medically

17-15

determined to have a physical or mental impairment which can be expected to result in death or

17-16

which has lasted or can be expected to last for a continuous period of not less than twelve (12)

17-17

months.

17-18

      (k) "Director" means the director of the department of business regulation.

17-19

      (l) [Deleted by P.L. 2006, ch. 258, section 2, and P.L. 2006, ch. 296, section 2.]

17-20

      (m) "Eligible employee" means an employee who works on a full-time basis with a

17-21

normal work week of thirty (30) or more hours, except that at the employer's sole discretion, the

17-22

term shall also include an employee who works on a full-time basis with a normal work week of

17-23

anywhere between at least seventeen and one-half (17.5) and thirty (30) hours, so long as this

17-24

eligibility criterion is applied uniformly among all of the employer's employees and without

17-25

regard to any health status-related factor. The term includes a self-employed individual, a sole

17-26

proprietor, a partner of a partnership, and may include an independent contractor, if the self-

17-27

employed individual, sole proprietor, partner, or independent contractor is included as an

17-28

employee under a health benefit plan of a small employer, but does not include an employee who

17-29

works on a temporary or substitute basis or who works less than seventeen and one-half (17.5)

17-30

hours per week. Any retiree under contract with any independently incorporated fire district is

17-31

also included in the definition of eligible employee, as well as any former employee of an

17-32

employer who retired before normal retirement age, as defined by 42 U.S.C. 18002(a)(2)(c) while

17-33

the employer participates in the early retiree reinsurance program defined by that chapter. Persons

17-34

covered under a health benefit plan pursuant to the Consolidated Omnibus Budget Reconciliation

18-1

Act of 1986 shall not be considered "eligible employees" for purposes of minimum participation

18-2

requirements pursuant to section 27-50-7(d)(9).

18-3

      (n) "Enrollment date" means the first day of coverage or, if there is a waiting period, the

18-4

first day of the waiting period, whichever is earlier.

18-5

      (o) "Established geographic service area" means a geographic area, as approved by the

18-6

director and based on the carrier's certificate of authority to transact insurance in this state, within

18-7

which the carrier is authorized to provide coverage.

18-8

      (p) "Family composition" means:

18-9

      (1) Enrollee;

18-10

      (2) Enrollee, spouse and children;

18-11

      (3) Enrollee and spouse; or

18-12

      (4) Enrollee and children.

18-13

      (q) "Genetic information" means information about genes, gene products, and inherited

18-14

characteristics that may derive from the individual or a family member. This includes information

18-15

regarding carrier status and information derived from laboratory tests that identify mutations in

18-16

specific genes or chromosomes, physical medical examinations, family histories, and direct

18-17

analysis of genes or chromosomes.

18-18

      (r) "Governmental plan" has the meaning given the term under section 3(32) of the

18-19

Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(32), and any federal

18-20

governmental plan.

18-21

      (s) (1) "Group health plan" means an employee welfare benefit plan as defined in section

18-22

3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(1), to the

18-23

extent that the plan provides medical care, as defined in subsection (y) of this section, and

18-24

including items and services paid for as medical care to employees or their dependents as defined

18-25

under the terms of the plan directly or through insurance, reimbursement, or otherwise.

18-26

      (2) For purposes of this chapter:

18-27

      (i) Any plan, fund, or program that would not be, but for PHSA Section 2721(e), 42

18-28

U.S.C. section 300gg(e), as added by P.L. 104-191, an employee welfare benefit plan and that is

18-29

established or maintained by a partnership, to the extent that the plan, fund or program provides

18-30

medical care, including items and services paid for as medical care, to present or former partners

18-31

in the partnership, or to their dependents, as defined under the terms of the plan, fund or program,

18-32

directly or through insurance, reimbursement or otherwise, shall be treated, subject to paragraph

18-33

(ii) of this subdivision, as an employee welfare benefit plan that is a group health plan;

19-34

      (ii) In the case of a group health plan, the term "employer" also includes the partnership

19-35

in relation to any partner; and

19-36

      (iii) In the case of a group health plan, the term "participant" also includes an individual

19-37

who is, or may become, eligible to receive a benefit under the plan, or the individual's beneficiary

19-38

who is, or may become, eligible to receive a benefit under the plan, if:

19-39

      (A) In connection with a group health plan maintained by a partnership, the individual is

19-40

a partner in relation to the partnership; or

19-41

      (B) In connection with a group health plan maintained by a self-employed individual,

19-42

under which one or more employees are participants, the individual is the self-employed

19-43

individual.

19-44

      (t) (1) "Health benefit plan" means any hospital or medical policy or certificate, major

19-45

medical expense insurance, hospital or medical service corporation subscriber contract, or health

19-46

maintenance organization subscriber contract. Health benefit plan includes short-term and

19-47

catastrophic health insurance policies, and a policy that pays on a cost-incurred basis, except as

19-48

otherwise specifically exempted in this definition.

19-49

      (2) "Health benefit plan" does not include one or more, or any combination of, the

19-50

following:

19-51

      (i) Coverage only for accident or disability income insurance, or any combination of

19-52

those;

19-53

      (ii) Coverage issued as a supplement to liability insurance;

19-54

      (iii) Liability insurance, including general liability insurance and automobile liability

19-55

insurance;

19-56

      (iv) Workers' compensation or similar insurance;

19-57

      (v) Automobile medical payment insurance;

19-58

      (vi) Credit-only insurance;

19-59

      (vii) Coverage for on-site medical clinics; and

19-60

      (viii) Other similar insurance coverage, specified in federal regulations issued pursuant

19-61

to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other

19-62

insurance benefits.

19-63

      (3) "Health benefit plan" does not include the following benefits if they are provided

19-64

under a separate policy, certificate, or contract of insurance or are otherwise not an integral part

19-65

of the plan:

19-66

      (i) Limited scope dental or vision benefits;

19-67

      (ii) Benefits for long-term care, nursing home care, home health care, community-based

19-68

care, or any combination of those; or

20-1

      (iii) Other similar, limited benefits specified in federal regulations issued pursuant to

20-2

Pub. L. No. 104-191.

20-3

      (4) "Health benefit plan" does not include the following benefits if the benefits are

20-4

provided under a separate policy, certificate or contract of insurance, there is no coordination

20-5

between the provision of the benefits and any exclusion of benefits under any group health plan

20-6

maintained by the same plan sponsor, and the benefits are paid with respect to an event without

20-7

regard to whether benefits are provided with respect to such an event under any group health plan

20-8

maintained by the same plan sponsor:

20-9

      (i) Coverage only for a specified disease or illness; or

20-10

      (ii) Hospital indemnity or other fixed indemnity insurance.

20-11

      (5) "Health benefit plan" does not include the following if offered as a separate policy,

20-12

certificate, or contract of insurance:

20-13

      (i) Medicare supplemental health insurance as defined under section 1882(g)(1) of the

20-14

Social Security Act, 42 U.S.C. section 1395ss(g)(1);

20-15

      (ii) Coverage supplemental to the coverage provided under 10 U.S.C. section 1071 et

20-16

seq.; or

20-17

      (iii) Similar supplemental coverage provided to coverage under a group health plan.

20-18

      (6) A carrier offering policies or certificates of specified disease, hospital confinement

20-19

indemnity, or limited benefit health insurance shall comply with the following:

20-20

      (i) The carrier files on or before March 1 of each year a certification with the director

20-21

that contains the statement and information described in paragraph (ii) of this subdivision;

20-22

      (ii) The certification required in paragraph (i) of this subdivision shall contain the

20-23

following:

20-24

      (A) A statement from the carrier certifying that policies or certificates described in this

20-25

paragraph are being offered and marketed as supplemental health insurance and not as a substitute

20-26

for hospital or medical expense insurance or major medical expense insurance; and

20-27

      (B) A summary description of each policy or certificate described in this paragraph,

20-28

including the average annual premium rates (or range of premium rates in cases where premiums

20-29

vary by age or other factors) charged for those policies and certificates in this state; and

20-30

      (iii) In the case of a policy or certificate that is described in this paragraph and that is

20-31

offered for the first time in this state on or after July 13, 2000, the carrier shall file with the

20-32

director the information and statement required in paragraph (ii) of this subdivision at least thirty

20-33

(30) days prior to the date the policy or certificate is issued or delivered in this state.

21-34

      (u) "Health maintenance organization" or "HMO" means a health maintenance

21-35

organization licensed under chapter 41 of this title.

21-36

      (v) "Health status-related factor" means any of the following factors:

21-37

      (1) Health status;

21-38

      (2) Medical condition, including both physical and mental illnesses;

21-39

      (3) Claims experience;

21-40

      (4) Receipt of health care;

21-41

      (5) Medical history;

21-42

      (6) Genetic information;

21-43

      (7) Evidence of insurability, including conditions arising out of acts of domestic

21-44

violence; or

21-45

      (8) Disability.

21-46

      (w) (1) "Late enrollee" means an eligible employee or dependent who requests

21-47

enrollment in a health benefit plan of a small employer following the initial enrollment period

21-48

during which the individual is entitled to enroll under the terms of the health benefit plan,

21-49

provided that the initial enrollment period is a period of at least thirty (30) days.

21-50

      (2) "Late enrollee" does not mean an eligible employee or dependent:

21-51

      (i) Who meets each of the following provisions:

21-52

      (A) The individual was covered under creditable coverage at the time of the initial

21-53

enrollment;

21-54

      (B) The individual lost creditable coverage as a result of cessation of employer

21-55

contribution, termination of employment or eligibility, reduction in the number of hours of

21-56

employment, involuntary termination of creditable coverage, or death of a spouse, divorce or

21-57

legal separation, or the individual and/or dependents are determined to be eligible for RIteCare

21-58

under chapter 5.1 of title 40 or chapter 12.3 of title 42 or for RIteShare under chapter 8.4 of title

21-59

40; and

21-60

      (C) The individual requests enrollment within thirty (30) days after termination of the

21-61

creditable coverage or the change in conditions that gave rise to the termination of coverage;

21-62

      (ii) If, where provided for in contract or where otherwise provided in state law, the

21-63

individual enrolls during the specified bona fide open enrollment period;

21-64

      (iii) If the individual is employed by an employer which offers multiple health benefit

21-65

plans and the individual elects a different plan during an open enrollment period;

21-66

      (iv) If a court has ordered coverage be provided for a spouse or minor or dependent child

21-67

under a covered employee's health benefit plan and a request for enrollment is made within thirty

21-68

(30) days after issuance of the court order;

22-1

      (v) If the individual changes status from not being an eligible employee to becoming an

22-2

eligible employee and requests enrollment within thirty (30) days after the change in status;

22-3

      (vi) If the individual had coverage under a COBRA continuation provision and the

22-4

coverage under that provision has been exhausted; or

22-5

      (vii) Who meets the requirements for special enrollment pursuant to section 27-50-7 or

22-6

27-50-8.

22-7

      (x) "Limited benefit health insurance" means that form of coverage that pays stated

22-8

predetermined amounts for specific services or treatments or pays a stated predetermined amount

22-9

per day or confinement for one or more named conditions, named diseases or accidental injury.

22-10

      (y) "Medical care" means amounts paid for:

22-11

      (1) The diagnosis, care, mitigation, treatment, or prevention of disease, or amounts paid

22-12

for the purpose of affecting any structure or function of the body;

22-13

      (2) Transportation primarily for and essential to medical care referred to in subdivision

22-14

(1); and

22-15

      (3) Insurance covering medical care referred to in subdivisions (1) and (2) of this

22-16

subsection.

22-17

      (z) "Network plan" means a health benefit plan issued by a carrier under which the

22-18

financing and delivery of medical care, including items and services paid for as medical care, are

22-19

provided, in whole or in part, through a defined set of providers under contract with the carrier.

22-20

      (aa) "Person" means an individual, a corporation, a partnership, an association, a joint

22-21

venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any

22-22

combination of the foregoing.

22-23

      (bb) "Plan sponsor" has the meaning given this term under section 3(16)(B) of the

22-24

Employee Retirement Income Security Act of 1974, 29 U.S.C. section 1002(16)(B).

22-25

      (cc) (1) "Preexisting condition" means a condition, regardless of the cause of the

22-26

condition, for which medical advice, diagnosis, care, or treatment was recommended or received

22-27

during the six (6) months immediately preceding the enrollment date of the coverage.: with

22-28

respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact

22-29

the condition was present before the date of enrollment for such coverage, whether or not any

22-30

medical advice, diagnosis, care, or treatment was recommended or received before such date.

22-31

      (2) "Preexisting condition" does not mean a condition for which medical advice,

22-32

diagnosis, care, or treatment was recommended or received for the first time while the covered

22-33

person held creditable coverage and that was a covered benefit under the health benefit plan,

22-34

provided that the prior creditable coverage was continuous to a date not more than ninety (90)

23-1

days prior to the enrollment date of the new coverage.

23-2

      (3) Genetic information shall not be treated as a condition under subdivision (1) of this

23-3

subsection for which a preexisting condition exclusion may be imposed in the absence of a

23-4

diagnosis of the condition related to the information.

23-5

      (dd) "Premium" means all moneys paid by a small employer and eligible employees as a

23-6

condition of receiving coverage from a small employer carrier, including any fees or other

23-7

contributions associated with the health benefit plan.

23-8

      (ee) "Producer" means any insurance producer licensed under chapter 2.4 of this title.

23-9

      (ff) "Rating period" means the calendar period for which premium rates established by a

23-10

small employer carrier are assumed to be in effect.

23-11

      (gg) "Restricted network provision" means any provision of a health benefit plan that

23-12

conditions the payment of benefits, in whole or in part, on the use of health care providers that

23-13

have entered into a contractual arrangement with the carrier pursuant to provide health care

23-14

services to covered individuals.

23-15

      (hh) "Risk adjustment mechanism" means the mechanism established pursuant to section

23-16

27-50-16.

23-17

      (ii) "Self-employed individual" means an individual or sole proprietor who derives a

23-18

substantial portion of his or her income from a trade or business through which the individual or

23-19

sole proprietor has attempted to earn taxable income and for which he or she has filed the

23-20

appropriate Internal Revenue Service Form 1040, Schedule C or F, for the previous taxable year.

23-21

      (jj) "Significant break in coverage" means a period of ninety (90) consecutive days

23-22

during all of which the individual does not have any creditable coverage, except that neither a

23-23

waiting period nor an affiliation period is taken into account in determining a significant break in

23-24

coverage.

23-25

      (kk) "Small employer" means, except for its use in section 27-50-7, any person, firm,

23-26

corporation, partnership, association, political subdivision, or self-employed individual that is

23-27

actively engaged in business including, but not limited to, a business or a corporation organized

23-28

under the Rhode Island Non-Profit Corporation Act, chapter 6 of title 7, or a similar act of

23-29

another state that, on at least fifty percent (50%) of its working days during the preceding

23-30

calendar quarter, employed no more than fifty (50) eligible employees, with a normal work week

23-31

of thirty (30) or more hours, the majority of whom were employed within this state, and is not

23-32

formed primarily for purposes of buying health insurance and in which a bona fide employer-

23-33

employee relationship exists. In determining the number of eligible employees, companies that

23-34

are affiliated companies, or that are eligible to file a combined tax return for purposes of taxation

24-1

by this state, shall be considered one employer. Subsequent to the issuance of a health benefit

24-2

plan to a small employer and for the purpose of determining continued eligibility, the size of a

24-3

small employer shall be determined annually. Except as otherwise specifically provided,

24-4

provisions of this chapter that apply to a small employer shall continue to apply at least until the

24-5

plan anniversary following the date the small employer no longer meets the requirements of this

24-6

definition. The term small employer includes a self-employed individual.

24-7

      (ll) "Waiting period" means, with respect to a group health plan and an individual who is

24-8

a potential enrollee in the plan, the period that must pass with respect to the individual before the

24-9

individual is eligible to be covered for benefits under the terms of the plan. For purposes of

24-10

calculating periods of creditable coverage pursuant to subsection (j)(2) of this section, a waiting

24-11

period shall not be considered a gap in coverage.

24-12

      (mm) "Wellness health benefit plan" means a plan developed pursuant to section 27-50-

24-13

10.

24-14

      (nn) "Health insurance commissioner" or "commissioner" means that individual

24-15

appointed pursuant to section 42-14.5-1 of the general laws and afforded those powers and duties

24-16

as set forth in sections 42-14.5-2 and 42-14.5-3 of title 42.

24-17

      (oo) "Low-wage firm" means those with average wages that fall within the bottom

24-18

quartile of all Rhode Island employers.

24-19

      (pp) "Wellness health benefit plan" means the health benefit plan offered by each small

24-20

employer carrier pursuant to section 27-50-7.

24-21

      (qq) "Commissioner" means the health insurance commissioner.

24-22

     27-50-7. Availability of coverage. -- (a) Until October 1, 2004, for purposes of this

24-23

section, "small employer" includes any person, firm, corporation, partnership, association, or

24-24

political subdivision that is actively engaged in business that on at least fifty percent (50%) of its

24-25

working days during the preceding calendar quarter, employed a combination of no more than

24-26

fifty (50) and no less than two (2) eligible employees and part-time employees, the majority of

24-27

whom were employed within this state, and is not formed primarily for purposes of buying health

24-28

insurance and in which a bona fide employer-employee relationship exists. After October 1, 2004,

24-29

for the purposes of this section, "small employer" has the meaning used in section 27-50-3(kk).

24-30

      (b) (1) Every small employer carrier shall, as a condition of transacting business in this

24-31

state with small employers, actively offer to small employers all health benefit plans it actively

24-32

markets to small employers in this state including a wellness health benefit plan. A small

24-33

employer carrier shall be considered to be actively marketing a health benefit plan if it offers that

24-34

plan to any small employer not currently receiving a health benefit plan from the small employer

25-1

carrier.

25-2

      (2) Subject to subdivision (1) of this subsection, a small employer carrier shall issue any

25-3

health benefit plan to any eligible small employer that applies for that plan and agrees to make the

25-4

required premium payments and to satisfy the other reasonable provisions of the health benefit

25-5

plan not inconsistent with this chapter. However, no carrier is required to issue a health benefit

25-6

plan to any self-employed individual who is covered by, or is eligible for coverage under, a health

25-7

benefit plan offered by an employer.

25-8

      (c) (1) A small employer carrier shall file with the director, in a format and manner

25-9

prescribed by the director, the health benefit plans to be used by the carrier. A health benefit plan

25-10

filed pursuant to this subdivision may be used by a small employer carrier beginning thirty (30)

25-11

days after it is filed unless the director disapproves its use.

25-12

      (2) The director may at any time may, after providing notice and an opportunity for a

25-13

hearing to the small employer carrier, disapprove the continued use by a small employer carrier of

25-14

a health benefit plan on the grounds that the plan does not meet the requirements of this chapter.

25-15

      (d) Health benefit plans covering small employers shall comply with the following

25-16

provisions:

25-17

      (1) A health benefit plan shall not deny, exclude, or limit benefits for a covered

25-18

individual for losses incurred more than six (6) months following the enrollment date of the

25-19

individual's coverage due to a preexisting condition, or the first date of the waiting period for

25-20

enrollment if that date is earlier than the enrollment date. A health benefit plan shall not define a

25-21

preexisting condition more restrictively than as defined in section 27-50-3.

25-22

      (2) (i) Except as provided in subdivision (3) of this subsection, a small employer carrier

25-23

shall reduce the period of any preexisting condition exclusion by the aggregate of the periods of

25-24

creditable coverage without regard to the specific benefits covered during the period of creditable

25-25

coverage, provided that the last period of creditable coverage ended on a date not more than

25-26

ninety (90) days prior to the enrollment date of new coverage.

25-27

      (ii) The aggregate period of creditable coverage does not include any waiting period or

25-28

affiliation period for the effective date of the new coverage applied by the employer or the carrier,

25-29

or for the normal application and enrollment process following employment or other triggering

25-30

event for eligibility.

25-31

      (iii) A carrier that does not use preexisting condition limitations in any of its health

25-32

benefit plans may impose an affiliation period that:

25-33

      (A) Does not exceed sixty (60) days for new entrants and not to exceed ninety (90) days

25-34

for late enrollees;

26-1

      (B) During which the carrier charges no premiums and the coverage issued is not

26-2

effective; and

26-3

      (C) Is applied uniformly, without regard to any health status-related factor.

26-4

      (iv) This section does not preclude application of any waiting period applicable to all

26-5

new enrollees under the health benefit plan, provided that any carrier-imposed waiting period is

26-6

no longer than sixty (60) days.

26-7

      (3) (i) Instead of as provided in paragraph (2)(i) of this subsection, a small employer

26-8

carrier may elect to reduce the period of any preexisting condition exclusion based on coverage of

26-9

benefits within each of several classes or categories of benefits specified in federal regulations.

26-10

      (ii) A small employer electing to reduce the period of any preexisting condition

26-11

exclusion using the alternative method described in paragraph (i) of this subdivision shall:

26-12

      (A) Make the election on a uniform basis for all enrollees; and

26-13

      (B) Count a period of creditable coverage with respect to any class or category of

26-14

benefits if any level of benefits is covered within the class or category.

26-15

      (iii) A small employer carrier electing to reduce the period of any preexisting condition

26-16

exclusion using the alternative method described under paragraph (i) of this subdivision shall:

26-17

      (A) Prominently state that the election has been made in any disclosure statements

26-18

concerning coverage under the health benefit plan to each enrollee at the time of enrollment under

26-19

the plan and to each small employer at the time of the offer or sale of the coverage; and

26-20

      (B) Include in the disclosure statements the effect of the election.

26-21

      (4) (i) A health benefit plan shall accept late enrollees, but may exclude coverage for late

26-22

enrollees for preexisting conditions for a period not to exceed twelve (12) months.

26-23

      (ii) A small employer carrier shall reduce the period of any preexisting condition

26-24

exclusion pursuant to subdivision (2) or (3) of this subsection.

26-25

      (5) A small employer carrier shall not impose a preexisting condition exclusion:

26-26

      (i) Relating to pregnancy as a preexisting condition; or

26-27

      (ii) With regard to a child who is covered under any creditable coverage within thirty

26-28

(30) days of birth, adoption, or placement for adoption, provided that the child does not

26-29

experience a significant break in coverage, and provided that the child was adopted or placed for

26-30

adoption before attaining eighteen (18) years of age.

26-31

      (6) A small employer carrier shall not impose a preexisting condition exclusion in the

26-32

case of a condition for which medical advice, diagnosis, care or treatment was recommended or

26-33

received for the first time while the covered person held creditable coverage, and the medical

26-34

advice, diagnosis, care or treatment was a covered benefit under the plan, provided that the

27-1

creditable coverage was continuous to a date not more than ninety (90) days prior to the

27-2

enrollment date of the new coverage.

27-3

      (7) (i) A small employer carrier shall permit an employee or a dependent of the

27-4

employee, who is eligible, but not enrolled, to enroll for coverage under the terms of the group

27-5

health plan of the small employer during a special enrollment period if:

27-6

      (A) The employee or dependent was covered under a group health plan or had coverage

27-7

under a health benefit plan at the time coverage was previously offered to the employee or

27-8

dependent;

27-9

      (B) The employee stated in writing at the time coverage was previously offered that

27-10

coverage under a group health plan or other health benefit plan was the reason for declining

27-11

enrollment, but only if the plan sponsor or carrier, if applicable, required that statement at the

27-12

time coverage was previously offered and provided notice to the employee of the requirement and

27-13

the consequences of the requirement at that time;

27-14

      (C) The employee's or dependent's coverage described under subparagraph (A) of this

27-15

paragraph:

27-16

      (I) Was under a COBRA continuation provision and the coverage under this provision

27-17

has been exhausted; or

27-18

      (II) Was not under a COBRA continuation provision and that other coverage has been

27-19

terminated as a result of loss of eligibility for coverage, including as a result of a legal separation,

27-20

divorce, death, termination of employment, or reduction in the number of hours of employment or

27-21

employer contributions towards that other coverage have been terminated; and

27-22

      (D) Under terms of the group health plan, the employee requests enrollment not later

27-23

than thirty (30) days after the date of exhaustion of coverage described in item (C)(I) of this

27-24

paragraph or termination of coverage or employer contribution described in item (C)(II) of this

27-25

paragraph.

27-26

      (ii) If an employee requests enrollment pursuant to subparagraph (i)(D) of this

27-27

subdivision, the enrollment is effective not later than the first day of the first calendar month

27-28

beginning after the date the completed request for enrollment is received.

27-29

      (8) (i) A small employer carrier that makes coverage available under a group health plan

27-30

with respect to a dependent of an individual shall provide for a dependent special enrollment

27-31

period described in paragraph (ii) of this subdivision during which the person or, if not enrolled,

27-32

the individual may be enrolled under the group health plan as a dependent of the individual and,

27-33

in the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a

27-34

dependent of the individual if the spouse is eligible for coverage if:

28-1

      (A) The individual is a participant under the health benefit plan or has met any waiting

28-2

period applicable to becoming a participant under the plan and is eligible to be enrolled under the

28-3

plan, but for a failure to enroll during a previous enrollment period; and

28-4

      (B) A person becomes a dependent of the individual through marriage, birth, or adoption

28-5

or placement for adoption.

28-6

      (ii) The special enrollment period for individuals that meet the provisions of paragraph

28-7

(i) of this subdivision is a period of not less than thirty (30) days and begins on the later of:

28-8

      (A) The date dependent coverage is made available; or

28-9

      (B) The date of the marriage, birth, or adoption or placement for adoption described in

28-10

subparagraph (i)(B) of this subdivision.

28-11

      (iii) If an individual seeks to enroll a dependent during the first thirty (30) days of the

28-12

dependent special enrollment period described under paragraph (ii) of this subdivision, the

28-13

coverage of the dependent is effective:

28-14

      (A) In the case of marriage, not later than the first day of the first month beginning after

28-15

the date the completed request for enrollment is received;

28-16

      (B) In the case of a dependent's birth, as of the date of birth; and

28-17

      (C) In the case of a dependent's adoption or placement for adoption, the date of the

28-18

adoption or placement for adoption.

28-19

      (9) (i) Except as provided in this subdivision, requirements used by a small employer

28-20

carrier in determining whether to provide coverage to a small employer, including requirements

28-21

for minimum participation of eligible employees and minimum employer contributions, shall be

28-22

applied uniformly among all small employers applying for coverage or receiving coverage from

28-23

the small employer carrier.

28-24

      (ii) For health benefit plans issued or renewed on or after October 1, 2000, a small

28-25

employer carrier shall not require a minimum participation level greater than seventy-five percent

28-26

(75%) of eligible employees.

28-27

      (iii) In applying minimum participation requirements with respect to a small employer, a

28-28

small employer carrier shall not consider employees or dependents who have creditable coverage

28-29

in determining whether the applicable percentage of participation is met.

28-30

      (iv) A small employer carrier shall not increase any requirement for minimum employee

28-31

participation or modify any requirement for minimum employer contribution applicable to a small

28-32

employer at any time after the small employer has been accepted for coverage.

28-33

      (10) (i) If a small employer carrier offers coverage to a small employer, the small

28-34

employer carrier shall offer coverage to all of the eligible employees of a small employer and

29-1

their dependents who apply for enrollment during the period in which the employee first becomes

29-2

eligible to enroll under the terms of the plan. A small employer carrier shall not offer coverage to

29-3

only certain individuals or dependents in a small employer group or to only part of the group.

29-4

      (ii) A small employer carrier shall not place any restriction in regard to any health status-

29-5

related factor on an eligible employee or dependent with respect to enrollment or plan

29-6

participation.

29-7

      (iii) Except as permitted under subdivisions (1) and (4) of this subsection, a small

29-8

employer carrier shall not modify a health benefit plan with respect to a small employer or any

29-9

eligible employee or dependent, through riders, endorsements, or otherwise, to restrict or exclude

29-10

coverage or benefits for specific diseases, medical conditions, or services covered by the plan.

29-11

      (e) (1) Subject to subdivision (3) of this subsection, a small employer carrier is not

29-12

required to offer coverage or accept applications pursuant to subsection (b) of this section in the

29-13

case of the following:

29-14

      (i) To a small employer, where the small employer does not have eligible individuals

29-15

who live, work, or reside in the established geographic service area for the network plan;

29-16

      (ii) To an employee, when the employee does not live, work, or reside within the

29-17

carrier's established geographic service area; or

29-18

      (iii) Within an area where the small employer carrier reasonably anticipates, and

29-19

demonstrates to the satisfaction of the director, that it will not have the capacity within its

29-20

established geographic service area to deliver services adequately to enrollees of any additional

29-21

groups because of its obligations to existing group policyholders and enrollees.

29-22

      (2) A small employer carrier that cannot offer coverage pursuant to paragraph (1)(iii) of

29-23

this subsection may not offer coverage in the applicable area to new cases of employer groups

29-24

until the later of one hundred and eighty (180) days following each refusal or the date on which

29-25

the carrier notifies the director that it has regained capacity to deliver services to new employer

29-26

groups.

29-27

      (3) A small employer carrier shall apply the provisions of this subsection uniformly to all

29-28

small employers without regard to the claims experience of a small employer and its employees

29-29

and their dependents or any health status-related factor relating to the employees and their

29-30

dependents.

29-31

      (f) (1) A small employer carrier is not required to provide coverage to small employers

29-32

pursuant to subsection (b) of this section if:

29-33

      (i) For any period of time the director determines the small employer carrier does not

29-34

have the financial reserves necessary to underwrite additional coverage; and

30-1

      (ii) The small employer carrier is applying this subsection uniformly to all small

30-2

employers in the small group market in this state consistent with applicable state law and without

30-3

regard to the claims experience of a small employer and its employees and their dependents or

30-4

any health status-related factor relating to the employees and their dependents.

30-5

      (2) A small employer carrier that denies coverage in accordance with subdivision (1) of

30-6

this subsection may not offer coverage in the small group market for the later of:

30-7

      (i) A period of one hundred and eighty (180) days after the date the coverage is denied;

30-8

or

30-9

      (ii) Until the small employer has demonstrated to the director that it has sufficient

30-10

financial reserves to underwrite additional coverage.

30-11

      (g) (1) A small employer carrier is not required to provide coverage to small employers

30-12

pursuant to subsection (b) of this section if the small employer carrier elects not to offer new

30-13

coverage to small employers in this state.

30-14

      (2) A small employer carrier that elects not to offer new coverage to small employers

30-15

under this subsection may be allowed, as determined by the director, to maintain its existing

30-16

policies in this state.

30-17

      (3) A small employer carrier that elects not to offer new coverage to small employers

30-18

under subdivision (g)(1) shall provide at least one hundred and twenty (120) days notice of its

30-19

election to the director and is prohibited from writing new business in the small employer market

30-20

in this state for a period of five (5) years beginning on the date the carrier ceased offering new

30-21

coverage in this state.

30-22

      (h) No small group carrier may impose a pre-existing condition exclusion pursuant to the

30-23

provisions of subdivisions 27-50-7(d)(1), 27-50-7(d)(2), 27-50-7(d)(3), 27-50-7(d)(4), 27-50-

30-24

7(d)(5) and 27-50-7(d)(6) with regard to an individual that is less than nineteen (19) years of age.

30-25

Notwithstanding any provision of this section or of any general or public law to the contrary,

30-26

With with respect to health benefit plans issued on and after January 1, 2014 a small employer

30-27

carrier shall offer and issue coverage to small employers and eligible individuals notwithstanding

30-28

any pre-existing condition of an employee, member, or individual, or their dependents.

30-29

     SECTION 14. Section 27-18.6-3 of the General Laws in Chapter 27-18.6 entitled "Large

30-30

Group Health Insurance Coverage" is hereby amended to read as follows:

30-31

     27-18.6-3. Limitation on preexisting condition exclusion. -- (a) (1) Notwithstanding

30-32

any of the provisions of this title to the contrary, a group health plan and a health insurance

30-33

carrier offering group health insurance coverage shall not deny, exclude, or limit benefits with

30-34

respect to a participant or beneficiary because of a preexisting condition exclusion except if:

31-1

      (i) The exclusion relates to a condition (whether physical or mental), regardless of the

31-2

cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended

31-3

or received within the six (6) month period ending on the enrollment date;

31-4

      (ii) The exclusion extends for a period of not more than twelve (12) months (or eighteen

31-5

(18) months in the case of a late enrollee) after the enrollment date; and

31-6

      (iii) The period of the preexisting condition exclusion is reduced by the aggregate of the

31-7

periods of creditable coverage, if any, applicable to the participant or the beneficiary as of the

31-8

enrollment date.

31-9

      (2) For purposes of this section, genetic information shall not be treated as a preexisting

31-10

condition in the absence of a diagnosis of the condition related to that information.

31-11

      (b) With respect to paragraph (a)(1)(iii) of this section, a period of creditable coverage

31-12

shall not be counted, with respect to enrollment of an individual under a group health plan, if,

31-13

after that period and before the enrollment date, there was a sixty-three (63) day period during

31-14

which the individual was not covered under any creditable coverage.

31-15

      (c) Any period that an individual is in a waiting period for any coverage under a group

31-16

health plan or for group health insurance or is in an affiliation period shall not be taken into

31-17

account in determining the continuous period under subsection (b) of this section.

31-18

      (d) Except as otherwise provided in subsection (e) of this section, for purposes of

31-19

applying paragraph (a)(1)(iii) of this section, a group health plan and a health insurance carrier

31-20

offering group health insurance coverage shall count a period of creditable coverage without

31-21

regard to the specific benefits covered during the period.

31-22

      (e) (1) A group health plan or a health insurance carrier offering group health insurance

31-23

may elect to apply paragraph (a)(1)(iii) of this section based on coverage of benefits within each

31-24

of several classes or categories of benefits. Those classes or categories of benefits are to be

31-25

determined by the secretary of the United States Department of Health and Human Services

31-26

pursuant to regulation. The election shall be made on a uniform basis for all participants and

31-27

beneficiaries. Under the election, a group health plan or carrier shall count a period of creditable

31-28

coverage with respect to any class or category of benefits if any level of benefits is covered

31-29

within the class or category.

31-30

      (2) In the case of an election under this subsection with respect to a group health plan

31-31

(whether or not health insurance coverage is provided in connection with that plan), the plan

31-32

shall:

31-33

      (i) Prominently state in any disclosure statements concerning the plan, and state to each

31-34

enrollee under the plan, that the plan has made the election; and

32-1

      (ii) Include in the statements a description of the effect of this election.

32-2

      (3) In the case of an election under this subsection with respect to health insurance

32-3

coverage offered by a carrier in the large group market, the carrier shall:

32-4

      (i) Prominently state in any disclosure statements concerning the coverage, and to each

32-5

employer at the time of the offer or sale of the coverage, that the carrier has made the election;

32-6

and

32-7

      (ii) Include in the statements a description of the effect of the election.

32-8

      (f) (1) A group health plan and a health insurance carrier offering group health insurance

32-9

coverage may not impose any preexisting condition exclusion in the case of an individual who, as

32-10

of the last day of the thirty (30) day period beginning with the date of birth, is covered under

32-11

creditable coverage.

32-12

      (2) Subdivision (1) of this subsection shall no longer apply to an individual after the end

32-13

of the first sixty-three (63) day period during all of which the individual was not covered under

32-14

any creditable coverage. Moreover, any period that an individual is in a waiting period for any

32-15

coverage under a group health plan (or for group health insurance coverage) or is in an affiliation

32-16

period shall not be taken into account in determining the continuous period for purposes of

32-17

determining creditable coverage.

32-18

      (g) (1) A group health plan and a health insurance carrier offering group health insurance

32-19

coverage may not impose any preexisting condition exclusion in the case of a child who is

32-20

adopted or placed for adoption before attaining eighteen (18) years of age and who, as of the last

32-21

day of the thirty (30) day period beginning on the date of the adoption or placement for adoption,

32-22

is covered under creditable coverage. The previous sentence does not apply to coverage before

32-23

the date of the adoption or placement for adoption.

32-24

      (2) Subdivision (1) of this subsection shall no longer apply to an individual after the end

32-25

of the first sixty-three (63) day period during all of which the individual was not covered under

32-26

any creditable coverage. Any period that an individual is in a waiting period for any coverage

32-27

under a group health plan (or for group health insurance coverage) or is in an affiliation period

32-28

shall not be taken into account in determining the continuous period for purposes of determining

32-29

creditable coverage.

32-30

      (h) A group health plan and a health insurance carrier offering group health insurance

32-31

coverage may not impose any preexisting condition exclusion relating to pregnancy as a

32-32

preexisting condition or with regard to an individual who is under nineteen (19) years of age.

32-33

      (i) (1) Periods of creditable coverage with respect to an individual shall be established

32-34

through presentation of certifications. A group health plan and a health insurance carrier offering

33-1

group health insurance coverage shall provide certifications:

33-2

      (i) At the time an individual ceases to be covered under the plan or becomes covered

33-3

under a COBRA continuation provision;

33-4

      (ii) In the case of an individual becoming covered under a continuation provision, at the

33-5

time the individual ceases to be covered under that provision; and

33-6

      (iii) On the request of an individual made not later than twenty-four (24) months after the

33-7

date of cessation of the coverage described in paragraph (i) or (ii) of this subdivision, whichever

33-8

is later.

33-9

      (2) The certification under this subsection may be provided, to the extent practicable, at a

33-10

time consistent with notices required under any applicable COBRA continuation provision.

33-11

      (3) The certification described in this subsection is a written certification of:

33-12

      (i) The period of creditable coverage of the individual under the plan and the coverage (if

33-13

any) under the COBRA continuation provision; and

33-14

      (ii) The waiting period (if any) (and affiliation period, if applicable) imposed with

33-15

respect to the individual for any coverage under the plan.

33-16

      (4) To the extent that medical care under a group health plan consists of group health

33-17

insurance coverage, the plan is deemed to have satisfied the certification requirement under this

33-18

subsection if the health insurance carrier offering the coverage provides for the certification in

33-19

accordance with this subsection.

33-20

      (5) In the case of an election taken pursuant to subsection (e) of this section by a group

33-21

health plan or a health insurance carrier, if the plan or carrier enrolls an individual for coverage

33-22

under the plan and the individual provides a certification of creditable coverage, upon request of

33-23

the plan or carrier, the entity which issued the certification shall promptly disclose to the

33-24

requisition plan or carrier information on coverage of classes and categories of health benefits

33-25

available under that entity's plan or coverage, and the entity may charge the requesting plan or

33-26

carrier for the reasonable cost of disclosing the information.

33-27

      (6) Failure of an entity to provide information under this subsection with respect to

33-28

previous coverage of an individual so as to adversely affect any subsequent coverage of the

33-29

individual under another group health plan or health insurance coverage, as determined in

33-30

accordance with rules and regulations established by the secretary of the United States

33-31

Department of Health and Human Services, is a violation of this chapter.

33-32

      (j) A group health plan and a health insurance carrier offering group health insurance

33-33

coverage in connection with a group health plan shall permit an employee who is eligible, but not

33-34

enrolled, for coverage under the terms of the plan (or a dependent of an employee if the

34-1

dependent is eligible, but not enrolled, for coverage under the terms) to enroll for coverage under

34-2

the terms of the plan if each of the following conditions are met:

34-3

      (1) The employee or dependent was covered under a group health plan or had health

34-4

insurance coverage at the time coverage was previously offered to the employee or dependent;

34-5

      (2) The employee stated in writing at the time that coverage under a group health plan or

34-6

health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or

34-7

carrier (if applicable) required a statement at the time and provided the employee with notice of

34-8

that requirement (and the consequences of the requirement) at the time;

34-9

      (3) The employee's or dependent's coverage described in subsection (j)(1):

34-10

      (i) Was under a COBRA continuation provision and the coverage under that provision

34-11

was exhausted; or

34-12

      (ii) Was not under a continuation provision and either the coverage was terminated as a

34-13

result of loss of eligibility for the coverage (including as a result of legal separation, divorce,

34-14

death, termination of employment, or reduction in the number of hours of employment) or

34-15

employer contributions towards the coverage were terminated; and

34-16

      (4) Under the terms of the plan, the employee requests enrollment not later than thirty

34-17

(30) days after the date of exhaustion of coverage described in paragraph (3)(i) of this subsection

34-18

or termination of coverage or employer contribution described in paragraph (3)(ii) of this

34-19

subsection.

34-20

      (k) (1) If a group health plan makes coverage available with respect to a dependent of an

34-21

individual, the individual is a participant under the plan (or has met any waiting period applicable

34-22

to becoming a participant under the plan and is eligible to be enrolled under the plan but for a

34-23

failure to enroll during a previous enrollment period), and a person becomes a dependent of the

34-24

individual through marriage, birth, or adoption or placement through adoption, the group health

34-25

plan shall provide for a dependent special enrollment period during which the person (or, if not

34-26

enrolled, the individual) may be enrolled under the plan as a dependent of the individual, and in

34-27

the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a

34-28

dependent of the individual if the spouse is eligible for coverage.

34-29

      (2) A dependent special enrollment period shall be a period of not less than thirty (30)

34-30

days and shall begin on the later of:

34-31

      (i) The date dependent coverage is made available; or

34-32

      (ii) The date of the marriage, birth, or adoption or placement for adoption (as the case

34-33

may be).

35-34

      (3) If an individual seeks to enroll a dependent during the first thirty (30) days of a

35-35

dependent special enrollment period, the coverage of the dependent shall become effective:

35-36

      (i) In the case of marriage, not later than the first day of the first month beginning after

35-37

the date the completed request for enrollment is received;

35-38

      (ii) In the case of a dependent's birth, as of the date of the birth; or

35-39

      (iii) In the case of a dependent's adoption or placement for adoption, the date of the

35-40

adoption or placement for adoption.

35-41

      (l) (1) A health maintenance organization which offers health insurance coverage in

35-42

connection with a group health plan and which does not impose any preexisting condition

35-43

exclusion allowed under subsection (a) of this section with respect to any particular coverage

35-44

option may impose an affiliation period for the coverage option, but only if that period is applied

35-45

uniformly without regard to any health status-related factors, and the period does not exceed two

35-46

(2) months (or three (3) months in the case of a late enrollee).

35-47

      (2) For the purposes of this subsection, an affiliation shall begin on the enrollment date.

35-48

      (3) An affiliation period under a plan shall run concurrently with any waiting period

35-49

under the plan.

35-50

      (4) The director may approve alternative methods from those described under this

35-51

subsection to address adverse selection.

35-52

      (m) For the purpose of determining creditable coverage pursuant to this chapter, no

35-53

period before July 1, 1996, shall be taken into account. Individuals who need to establish

35-54

creditable coverage for periods before July 1, 1996, and who would have the coverage credited

35-55

but for the prohibition in the preceding sentence may be given credit for creditable coverage for

35-56

those periods through the presentation of documents or other means in accordance with any rule

35-57

or regulation that may be established by the secretary of the United States Department of Health

35-58

and Human Services.

35-59

      (n) In the case of an individual who seeks to establish creditable coverage for any period

35-60

for which certification is not required because it relates to an event occurring before June 30,

35-61

1996, the individual may present other credible evidence of coverage in order to establish the

35-62

period of creditable coverage. The group health plan and a health insurance carrier shall not be

35-63

subject to any penalty or enforcement action with respect to the plan's or carrier's crediting (or not

35-64

crediting) the coverage if the plan or carrier has sought to comply in good faith with the

35-65

applicable requirements of this section.

35-66

      (o) Notwithstanding the provisions of this section, or of any general or public law to the

35-67

contrary, for plan or policy years beginning on and after January 1, 2014, a group health plan and

35-68

a health insurance carrier offering group health insurance coverage shall not deny, exclude, or

36-1

limit benefits with respect to a participant or beneficiary because of a preexisting condition

36-2

exclusion.

36-3

     SECTION 15. This act shall take effect upon passage.

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LC00740/SUB A

========

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO INSURANCE -- GENDER RATING

***

37-1

     This act would provide that insurance companies shall not vary the premium rates

37-2

charged for a health coverage plan based on the gender of the individual policy holder, enrollee,

37-3

subscriber, or member.

37-4

     This act would take effect upon passage.

=======

LC00740/SUB A

=======