376.966. No employee to lose coverage by enrolling in pool--eligibility for pool coverage, ineligibility--medical underwriting considerations, notification required, when.
No employee to lose coverage by enrolling in pool--eligibility forpool coverage, ineligibility--medical underwritingconsiderations, notification required, when.
376.966. 1. No employee shall involuntarily lose his or her groupcoverage by decision of his or her employer on the grounds that suchemployee may subsequently enroll in the pool. The department shall haveauthority to promulgate rules and regulations to enforce this subsection.
2. The following individual persons shall be eligible for coverageunder the pool if they are and continue to be residents of this state:
(1) An individual person who provides evidence of the following:
(a) A notice of rejection or refusal to issue substantially similarhealth insurance for health reasons by at least two insurers; or
(b) A refusal by an insurer to issue health insurance except at arate exceeding the plan rate for substantially similar health insurance;
(2) A federally defined eligible individual who has not experienced asignificant break in coverage;
(3) A trade act eligible individual;
(4) Each resident dependent of a person who is eligible for plancoverage;
(5) Any person, regardless of age, that can be claimed as a dependentof a trade act eligible individual on such trade act eligible individual'stax filing;
(6) Any person whose health insurance coverage is involuntarilyterminated for any reason other than nonpayment of premium or fraud, andwho is not otherwise ineligible under subdivision (4) of subsection 3 ofthis section. If application for pool coverage is made not later thansixty-three days after the involuntary termination, the effective date ofthe coverage shall be the date of termination of the previous coverage;
(7) Any person whose premiums for health insurance coverage haveincreased above the rate established by the board under paragraph (a) ofsubdivision (1) of subsection 3 of this section;
(8) Any person currently insured who would have qualified as afederally defined eligible individual or a trade act eligible individualbetween the effective date of the federal Health Insurance Portability andAccountability Act of 1996, Public Law 104-191 and the effective date ofthis act*.
3. The following individual persons shall not be eligible forcoverage under the pool:
(1) Persons who have, on the date of issue of coverage by the pool,or obtain coverage under health insurance or an insurance arrangementsubstantially similar to or more comprehensive than a plan policy, or wouldbe eligible to have coverage if the person elected to obtain it, exceptthat:
(a) This exclusion shall not apply to a person who has such coveragebut whose premiums have increased to one hundred fifty percent to twohundred percent of rates established by the board as applicable forindividual standard risks;
(b) A person may maintain other coverage for the period of time theperson is satisfying any preexisting condition waiting period under a poolpolicy; and
(c) A person may maintain plan coverage for the period of time theperson is satisfying a preexisting condition waiting period under anotherhealth insurance policy intended to replace the pool policy;
(2) Any person who is at the time of pool application receivinghealth care benefits under section 208.151, RSMo;
(3) Any person having terminated coverage in the pool unless twelvemonths have elapsed since such termination, unless such person is afederally defined eligible individual;
(4) Any person on whose behalf the pool has paid out one milliondollars in benefits;
(5) Inmates or residents of public institutions, unless such personis a federally defined eligible individual, and persons eligible for publicprograms;
(6) Any person whose medical condition which precludes otherinsurance coverage is directly due to alcohol or drug abuse orself-inflicted injury, unless such person is a federally defined eligibleindividual or a trade act eligible individual;
(7) Any person who is eligible for Medicare coverage.
4. Any person who ceases to meet the eligibility requirements of thissection may be terminated at the end of such person's policy period.
5. If an insurer issues one or more of the following or takes anyother action based wholly or partially on medical underwritingconsiderations which is likely to render any person eligible for poolcoverage, the insurer shall notify all persons affected of the existence ofthe pool, as well as the eligibility requirements and methods of applyingfor pool coverage:
(1) A notice of rejection or cancellation of coverage;
(2) A notice of reduction or limitation of coverage, includingrestrictive riders, if the effect of the reduction or limitation is tosubstantially reduce coverage compared to the coverage available to aperson considered a standard risk for the type of coverage provided by theplan.
(L. 1990 H.B. 998 § 3, A.L. 2007 H.B. 818, A.L. 2009 H.B. 218)*"This act" (H.B. 818, 2007) contained effective dates of August 28, 2007, and January 1, 2008; H.B. 218, 2009, became effective August 28, 2009.