W. Va. Code R. § 114-55-3

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

Section 114-55-3 - Election of Coverage

3.1. Except as provided in subsection 3.2, an insurer that provides accident and sickness insurance coverage in the individual market may not decline to offer coverage or deny enrollment under any policy form it actively markets in the individual market to any eligible individual who applies for coverage within sixty-three days after termination of the individual's prior creditable coverage. An insurer is deemed to meet this requirement if, upon the request of an eligible individual, it promptly:

a. Provides information about all available coverage options;

b. Enrolls the individual in any coverage option the individual selects; and

c. Does not impose any preexisting condition exclusion on the individual.

3.2. An insurer may elect to limit the coverage required under subsection 3.1 if it offers eligible individuals at least two policy forms that meet the following requirements:

a. Each policy form must be designed for, made generally available to, and actively marketed to, and enroll both eligible and other individuals; and

b. The policy forms must be either the insurer's two most popular policy forms (as described in paragraph 1 of this subdivision and as set forth in W. Va. Code '33-15-2b) or representative samples of individual accident and sickness insurance (as described in paragraph 2 of this subdivision and as set forth in W. Va. Code '33-15-2b) offered by the insurer in this State.

1. The two most popular forms means the policy forms with the largest, and the second largest, premium volume for the last reporting year, for policies offered in the State. Premium volume means earned premiums for the last reporting year. The last reporting year is the period from October 1 through September 30 of the preceding year. Blocks of business closed under applicable State law are not included in calculating premium volume.

2. The two representative policy forms must meet the following requirements:

A. Include a lower-level coverage policy form under which the actuarial value of benefits under the coverage is at least 85 percent but not greater than 100 percent of the weighted average; and

B. Include a higher level coverage policy form under which the actuarial value of the benefits under the coverage is at least 15 percent greater than the actuarial value of the lower-level coverage policy form offered by an insurer in the State and at least 100 percent, but not greater than 120 percent of the weighted average;

C. Include benefits substantially similar to other individual accident and sickness insurance coverage offered by the insurer in the state;

D. Provide for risk adjustment, risk spreading, or a risk spreading mechanism, or otherwise provide some financial subsidization for eligible individuals; and

E. Meet all applicable State requirements.

3.3. All elections by insurers as provided for in subsection 3.2 of this rule must be applied uniformly to all eligible individuals in the State and must be effective for all policies offered during a period of at least two years.

3.4. Insurers making elections must do so on a form prescribed by the Commissioner within the following time frames:

a. For policy forms already being marketed as of July 1, 1997--no later than September 1, 1997.

b. For other policy forms--90 days before the beginning of the calendar year in which the insurer wants to market the policy form.

W. Va. Code R. § 114-55-3