379.940. Carriers to offer all health plans in market--health benefit plans, requirements--exclusion of coverage for certain employees.
Carriers to offer all health plans in market--health benefit plans,requirements--exclusion of coverage for certain employees.
379.940. 1. (1) Every small employer carrier shall, as a conditionof transacting business in this state with small employers, actively offerto small employers all health benefit plans it actively markets to smallemployers in this state, except for plans developed for health benefittrust funds.
(2) (a) A small employer carrier shall issue a health benefit planto any eligible small employer that applies for either such plan and agreesto make the required premium payments and to satisfy the other reasonableprovisions of the health benefit plan not inconsistent with sections379.930 to 379.952.
(b) In the case of a small employer carrier that establishes morethan one class of business pursuant to section 379.934, the small employercarrier shall maintain and issue to eligible small employers all healthbenefit plans in each class of business so established. A small employercarrier may apply reasonable criteria in determining whether to accept asmall employer into a class of business, provided that:
a. The criteria are not intended to discourage or prevent acceptanceof small employers applying for a health benefit plan;
b. The criteria are not related to the health status or claimexperience of the small employer;
c. The criteria are applied consistently to all small employersapplying for coverage in the class of business; and
d. The small employer carrier provides for the acceptance of alleligible small employers into one or more classes of business. Theprovisions of this paragraph shall not apply to a class of business intowhich the small employer carrier is no longer enrolling new smallemployers.
2. Health benefit plans covering small employers shall comply withthe following provisions:
(1) A health benefit plan shall comply with the provisions ofsections 376.450 and 376.451, RSMo.
(2) (a) Except as provided in paragraph (d) of this subdivision,requirements used by a small employer carrier in determining whether toprovide coverage to a small employer, including requirements for minimumparticipation of eligible employees and minimum employer contributions,shall be applied uniformly among all small employers with the same numberof eligible employees applying for coverage or receiving coverage from thesmall employer carrier.
(b) A small employer carrier shall not require a minimumparticipation level greater than:
a. One hundred percent of eligible employees working for groups ofthree or less employees; and
b. Seventy-five percent of eligible employees working for groups withmore than three employees.
(c) In applying minimum participation requirements with respect to asmall employer, a small employer carrier shall not consider employees ordependents who have qualifying existing coverage in determining whether theapplicable percentage of participation is met.
(d) A small employer carrier shall not increase any requirement forminimum employee participation or modify any requirement for minimumemployer contribution applicable to a small employer at any time after thesmall employer has been accepted for coverage.
(3) (a) If a small employer carrier offers coverage to a smallemployer, the small employer carrier shall offer coverage to all of theeligible employees of a small employer and their dependents who apply forenrollment during the period in which the employee first becomes eligibleto enroll under the terms of the plan. A small employer carrier shall notoffer coverage to only certain individuals or dependents in a smallemployer group or to only part of the group.
(b) A small employer carrier shall not modify a health benefit planwith respect to a small employer or any eligible employee or dependentthrough riders, endorsements or otherwise, to restrict or exclude coveragefor certain diseases or medical conditions otherwise covered by the healthbenefit plan.
(c) An eligible employee may choose to retain their individuallyunderwritten health benefit plan at the time such eligible employee isentitled to enroll in a small employer health benefit plan. If theeligible employee retains their individually underwritten health benefitplan, a small employer may provide a defined contribution through theestablishment of a cafeteria 125 plan under section 379.953*. Smallemployers shall establish an equal amount of defined contribution for allplans. If an eligible employee retains their individually underwrittenhealth benefit plan under this subdivision, the provisions of sections379.930 to 379.952 shall not apply to the individually underwritten healthbenefit plan.
3. (1) Subject to subdivision (3) of this subsection, a smallemployer carrier shall not be required to offer coverage or acceptapplications pursuant to subsection 1 of this section in the case of thefollowing:
(a) To a small employer, where the small employer is not physicallylocated in the carrier's established geographic service area;
(b) To an employee, when the employee does not live, work or residewithin the carrier's established geographic service area; or
(c) Within an area where the small employer carrier reasonablyanticipates, and demonstrates to the satisfaction of the director, that itwill not have the capacity within its established geographic service areato deliver service adequately to the members of such groups because of itsobligations to existing group policyholders and enrollees.
(2) A small employer carrier that cannot offer coverage pursuant toparagraph (c) of subdivision (1) of this subsection may not offer coveragein the applicable area to new cases of employer groups with more than fiftyeligible employees or to any small employer groups until the later of onehundred eighty days following each such refusal or the date on which thecarrier notifies the director that it has regained capacity to deliverservices to small employer groups.
(3) A small employer carrier shall apply the provisions of thissubsection uniformly to all small employers without regard to the claimsexperience of a small employer and its employees and their dependents orany health status-related factor relating to such employees and theirdependents.
4. A small employer carrier shall not be required to provide coverageto small employers pursuant to subsection 1 of this section for any periodof time for which the director determines that requiring the acceptance ofsmall employers in accordance with the provisions of subsection 1 of thissection would place the small employer carrier in a financially impairedcondition, and the small employer is applying this subsection uniformly toall small employers in the small group market in this state consistent withapplicable state law and without regard to the claims experience of a smallemployer and its employees and their dependents or any healthstatus-related factor relating to such employees and their dependents.
(L. 1992 S.B. 796 §§ 6, B, A.L. 2007 H.B. 818)Effective 1-01-08
*Section 379.953 does not exist.