56-7-2208 - Plans of coverage.
56-7-2208. Plans of coverage.
(a) To improve the availability and affordability of health benefits coverage for small employers, the committee shall recommend to the commissioner two (2) plans of coverage, one (1) of which shall be a basic health care plan and the other of which shall be a standard health care plan. Each plan of coverage shall be in two (2) forms, one (1) of which shall be in the form of insurance, and the other of which shall be consistent with the basic method of operation and benefit plans of HMOs, including federally qualified HMOs. The committee shall submit the recommended plans to the commissioner for approval within one hundred eighty (180) days after the appointment of the committee under § 56-7-2207. The committee shall take into consideration the levels of health benefit plans provided in this state, and appropriate medical and economic factors, and shall establish benefit levels, cost-sharing, exclusions and limitations. Notwithstanding subsection (c), in developing and approving the plans, the committee and the commissioner shall give due consideration to cost-effective and life-saving health care services and to cost-effective health care providers. The committee shall file with the commissioner its findings and recommendations, and reasons for the findings and recommendations, if it does not provide for coverage by any type of health care provider specified in part 24 of this chapter. The recommended plans may include cost containment features, including, but not limited to preferred provider provisions, utilization review of medical necessity of hospital and physician services, case management benefit alternatives, or other managed care provisions.
(b) The commissioner shall approve, modify, or disapprove the plans submitted by the committee after a public hearing held pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, part 2.
(c) After the commissioner's approval of the plans submitted by the committee under subsection (a) and in lieu of any contrary procedure established by this part, any small employer carrier may certify to the commissioner, in the form and manner prescribed by the commissioner, that the basic and standard health care plans filed by the carrier are in substantial compliance with the corresponding approved committee plans. Upon receipt by the commissioner of the certification, the carrier may use the certified plans unless their use is disapproved by the commissioner.
(d) The plans developed under this section are not required to provide coverage that meets the requirements of this part that mandate either coverage or the offer of coverage by the type or level of health care services or health care provider. Any such mandates included in the basic plans shall be limited to those that are essential to the provision of basic primary care.
(e) Within one hundred eighty (180) days after the commissioner's approval under subsection (b), every small employer carrier shall, as a condition of transacting business in this state, offer small employers at least one (1) basic and one (1) standard health care plan. Every small employer that elects to be covered under such a plan and agrees to make the required premium payments and to satisfy the other provisions of the plan shall be issued a plan by the small employer carrier; provided, that only small employers that have been without health insurance for the preceding six (6) calendar months are eligible to purchase the basic health care plan. After this part has been in effect for one (1) year, the six (6) calendar months eligibility requirement set forth above shall no longer apply. The premium payment requirements used in connection with basic and standard health care plans may address the potential credit risk of small employers that elect coverage in accordance with this subsection (e) by means of payment security provisions that are reasonably related to the risk and are uniformly applied.
(f) No small employer carrier is required to offer coverage or accept applications under subsection (d):
(1) From a group already covered under a health benefit plan, except for coverage that is to begin after the group's anniversary date, but this subsection (f) shall not be construed to prohibit a group from seeking coverage or a small employer carrier from issuing coverage to a group before its anniversary date;
(2) If the commissioner determines that acceptance of an application or applications would result in the carrier being declared an impaired insurer; or
(3) (A) To groups of fewer than five (5) eligible employees where the small employer carrier does not use preexisting conditions provisions in all health benefit plans it uses to any small employers;
(B) If a small employer carrier who does not use preexisting conditions chooses to market to groups of less than five (5), then it shall immediately notify the commissioner and the board, and it shall do so consistently and equally to all such small employer groups.
(g) Every small employer carrier shall fairly market the basic and standard health care plan to all small employers in the geographic areas in which the carrier makes coverage available or provides benefits.
(h) No HMO operating as either a risk-assuming carrier or a reinsuring carrier is required to offer coverage or accept applications under subsection (d) in the case of any of the following:
(1) To a group, where the group is not physically located in the HMO's approved service areas;
(2) To an employee, where the employee does not reside within the HMO's approved service areas; or
(3) (A) Within an area, where the HMO reasonably anticipates and demonstrates to the commissioner's satisfaction that it will not have the capacity within that area and its network of providers to deliver services adequately to the enrollees of those groups because of its obligations to existing group contract holders and enrollees;
(B) An HMO that does not offer coverage pursuant to subdivision (h)(3)(A) may not offer coverage in the applicable area to new employer groups with more than twenty-five (25) eligible employees until the later of ninety (90) days after that closure or the date on which the carrier notifies the commissioner that it has regained capacity to deliver services to small employers.
(i) Subsections (b), (d) and (g) and subdivision (h)(2) apply to every health benefit plan delivered, issued for delivery, renewed or continued in this state or covering persons residing in this state on or after the date the plan becomes operational, as determined by the commissioner. For purposes of this subsection (i), the date a health benefit plan is continued is the anniversary date of the issuance of the health benefit plan.
[Acts 1992, ch. 808, § 8.]