W. Va. Code R. § 114-54-9

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

Section 114-54-9 - Guaranteed Availability for Small Employers

9.1. Except as provided in subsections 9.2 through 9.5, a health insurer that offers health benefit plans to small employers in this state shall:

a. Offer to any small employer in this state all health benefit plans that are approved for sale to small employers and that the health insurer is actively marketing;

b. Accept any small employer that applies for any health benefit plan approved for sale to small employers and actively marketed by the health insurer; and

c. Under a health benefit plan issued to a small employer, accept for enrollment every individual who is eligible:

1. To enroll under the health benefit plan in accordance with terms of the group health plan in connection with which the health benefit plan is issued;

2. For coverage under rules of the health insurer that are uniformly applicable in this state to small employers to which the health insurer offers health benefit plans; and

3. For coverage in accordance with W. Va. Code chapter thirty-three, and other applicable law;

d. With respect to an individual who meets the requirements of paragraphs 1 through 3 of subdivision c of subsection 9.1, a health insurer:

1. Shall accept the individual for enrollment during the period in which he or she first becomes eligible to enroll under terms of the group health plan, or during a special enrollment period; and

2. May not impose any restriction inconsistent with section seven of this rule.

9.2. A health insurer that offers health benefit plans to small employers through a network plan:

a. May limit small employers that apply for the coverage to those with eligible employees (and dependents, if applicable) who live, reside or work in the network plan's service area; and

b. May deny coverage to small employers within the network plan's service area if the health insurer demonstrates to the commissioner that it:

1. Will not have the capacity to deliver services adequately to enrollees of any additional groups because of its obligations to existing group contract holders and enrollees;

2. Is applying subdivisions a and b of subsection 9.2 uniformly to all small employers without regard to the claims experience of those small employers, their employees and dependents or any health-status related factor relating to those employees and dependents; and

c. May not, if it denies coverage to a small employer in any service area under subdivision b of subsection 9.2, offer coverage to small employers within the service area for a period of one hundred eighty days after coverage is denied, but this subdivision does not limit a health insurer's ability to renew coverage already in force or relieve the issuer of the responsibility to renew that coverage. Network plans offered within a service area after the one hundred eighty-day period specified in this subdivision are subject to the requirements of this section.

9.3. A health insurer may deny coverage to small employers if the health insurer:

a. Demonstrates to the commissioner that it:

1. Does not have the financial reserves necessary to underwrite additional health benefit plans of small employers in this state, or for a network plan whose service areas have been approved by the commissioner, within one or more particular service areas; and

2. Is applying paragraph 1 of subdivision a of subsection 9.3 uniformly to all small employers without regard to the claims experience of those small employers, their employees and dependents or any health-status related factor relating to those employees and dependents; and

b. May not, if it denies coverage to any small employer in this state under paragraph 1 of subdivision a of subsection 9.3, offer health benefit plans to small employers in this state for a period of one hundred eighty days after the later of:

1. The date coverage is denied; or

2. The health insurer demonstrates to the commissioner that the health insurer has sufficient financial reserves to underwrite additional coverage;

c. This subsection does not limit a health insurer's ability to renew coverage already in force or relieve the health insurer of the responsibility to renew that coverage; and

d. Health benefit plans offered to small employers after the one hundred eighty-day period specified in subdivision b of subsection 9.3 are subject to the requirements of this section.

9.4. A health insurer may establish, and apply to a small employer applying for a health benefit plan, employer contribution rules or group participation rules permitted under W. Va. Code chapter thirty-three. For purposes of this subsection, "employer contribution rule" means a requirement relating to the minimum level or amount of employer contribution toward the premium for enrollment of eligible employees and dependents, and "group participation rule" means a requirement relating to the minimum number of eligible employees or dependents who must be enrolled in relation to a specified percentage or number of eligible individuals or employees of a small employer.

9.5. A health insurer offering a health benefit plan to small employers only through one or more bona fide associations is not required to meet the requirements of subsection 9.1.

W. Va. Code R. § 114-54-9