56-7-2207 - Small employer carrier committee.
56-7-2207. Small employer carrier committee.
(a) (1) The commissioner shall appoint the small employer carrier committee with fair representation of:
(A) Risk-assuming carriers and reinsuring carriers;
(B) The insurance agent and small employer communities; and
(C) Consumers who are served by plans covered by this part.
(2) The commissioner shall also appoint three (3) representatives from the health care profession who are licensed to practice medicine in this state. Two thirds (2/3) of the committee shall be appointed from among representatives of small employer carriers.
(b) Subject to the commissioner's approval, the committee shall recommend the form and level of coverages to be made available by small employer carriers in accordance with § 56-7-2208(a). The committee shall recommend benefit levels, cost-sharing factors, exclusions and limitations for the basic and standard health care plans. One (1) basic health care plan and one (1) standard health care plan shall contain benefit and cost-sharing levels that are consistent with the basic method of operation and the benefit plans of HMOs, including any restrictions imposed by federal law. The committee shall submit the plans to the commissioner for approval within one hundred eighty (180) days after the committee's appointment according to this section. The plans may include cost containment features such as:
(1) Utilization review of health care services, including review of medical necessity of hospital and physician services;
(2) Case management benefit alternatives;
(3) Selective contracting with hospitals, physicians and other health care providers;
(4) Reasonable benefit differentials applicable to participating and non-participating providers; and
(5) Other managed care provisions.
(c) To assure the broadest availability of health benefit plans to small employers, the committee shall recommend for the commissioner's approval market conduct and other requirements for carriers, agents, brokers and third-party administrators, including requirements developed as a result of a request by the commissioner relating to the following:
(1) Registration of each carrier with the department of its intention to be a small employer carrier under this part;
(2) Publication by the department, the committee or the pool of a list of all small employer carriers, including a potential requirement applicable to agents, brokers, third-party administrators and carriers that no health benefit plan may be sold to a small employer by a carrier not identified as a small employer carrier;
(3) The availability of a broadly publicized toll-free telephone number for access by small employers to information concerning this part;
(4) To the extent deemed to be necessary by the committee, to assure the fair distribution of high-risk individuals and groups among carriers, periodic reports by carriers, agents, brokers and third-party administrators about health benefit plans issued; provided, that reporting requirements shall be limited to information concerning case characteristics and numbers of health benefit plans in various categories marketed or issued to small employers;
(5) Registration by agents, brokers and third-party administrators of their intention to be agents, brokers and third-party administrators for health benefit plans marketed to small employers under this part;
(6) Methods concerning periodic demonstration by small employer carriers, agents, brokers and third-party administrators that they are marketing and issuing health benefit plans to small employers in fulfillment of the purposes of this part; and
(7) Establishing standards for those conditions under which a carrier would not be required to write business received from a particular agent or broker.
(d) (1) Within two (2) years of policy writing experience under this part, and, at a minimum, every two (2) years thereafter for a period of ten (10) years and from time to time after the ten-year period, the committee shall study the effectiveness of this part, recommend further improvements to achieve greater stability, accessibility and affordability in the small employer marketplace, and submit study summary and recommendations to the commissioner, the speaker of the senate, the speaker of the house of representatives, the commerce, labor and agriculture committees of the senate and the commerce committee of the house of representatives.
(2) The committee, in conjunction with the commissioner, shall study the feasibility of increasing the maximum number of eligible employees to a number greater than twenty-five (25) as contained in the present definition of small employer in § 56-7-2203.
[Acts 1992, ch. 808, § 7; 1996, ch. 1040, §§ 1, 2.]