W. Va. Code R. § 114-54-6

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-54-6 - Renewability and Modification of Coverage

6.1. Except as provided in subsection 6.2, a health insurer shall renew or continue in force a health benefit plan at the policyholder's option. In the case of a health benefit plan offered only through one or more associations, a reference to "policyholder" is deemed, with respect to coverage provided to an employer member of the association, to include a reference to the employer.

6.2. A health insurer may non renew or discontinue a health benefit plan only at the policyholder's option or for one of the following reasons:

a. The policyholder has failed to pay premiums or contributions in accordance with the terms of the health benefit plan, including any timeliness requirements;

b. The policyholder has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact in connection with the coverage;

c. The policyholder has failed to comply with a material plan provision relating to employer contribution or group participation rules permitted under W. Va. Code chapter thirty-three;

d. The health insurer elects to discontinue offering health benefit plans:

1. Of a particular type offered to large employers or to small employers, respectively, if:

A. The health insurer gives written notice to each policyholder of that product and all covered individuals at least ninety days before the date the coverage will be discontinued;

B. On a guaranteed issue basis, the health insurer offers each large employer policyholder the option to purchase any other health benefit plan currently being offered by the health insurer to large employers, or offers each small employer policyholder the option to purchase all other health benefit plans currently being offered by the health insurer to small employers; and

C. In electing to discontinue health benefit plans of a particular type and in offering coverage under the subparagraph B of paragraph 1 of subdivision d of subsection 6.2, the health insurer acts uniformly without regard to policyholders' claims experience or any health status-related factor relating to any covered employee, member or dependent or new employees, members or dependents who may become eligible for coverage; or

2. Of all types offered to large employers or to small employers, respectively, if:

A. The health insurer gives written notice to the commissioner and to each policyholder and all covered individuals at least one hundred eighty days before the date plans are discontinued; and

B. The health insurer discontinues all, and does not renew any, health benefit plans issued to large employers or to small employers, respectively;

e. For network plans, there is no longer any enrollee under the group health plan who lives, resides or works in the health insurer's service area, and, in the case of a small employer policyholder, the health insurer applies the same criteria it would apply in denying enrollment in the health benefit plan under section seven of this rule; or

f. For a health benefit plan made available to employers only through one or more bona fide associations, the employer's membership in the association ceases, but only if the coverage is terminated uniformly without regard to any health status-related factor relating to any covered individual.

6.3. A health insurer that elects to discontinue health benefit plans of all types offered to large employers or to small employers, respectively, in this state pursuant to paragraph 2 of subdivision d of subsection 6.2 may not issue any health benefit plan to a large employer or to a small employer, respectively, in this state for a five-year period beginning on the date of discontinuation of the last health benefit plan not renewed.

6.4. A health insurer may modify a health benefit plan's benefits only at the time of health benefit plan renewal. For health benefit plans available to small employers, other than only through one or more bona fide associations, a modification shall be effective uniformly among group health plans with that product and shall meet all other requirements under W. Va. Code chapter thirty-three.

W. Va. Code R. § 114-54-6