31A-8-402.3 - Discontinuance, nonrenewal, or changes to group health benefit plans.
31A-8-402.3. Discontinuance, nonrenewal, or changes to group health benefitplans.
(1) Except as otherwise provided in this section, a group health benefit plan for a plansponsor is renewable and continues in force:
(a) with respect to all eligible employees and dependents; and
(b) at the option of the plan sponsor.
(2) A health benefit plan for a plan sponsor may be discontinued or nonrenewed:
(a) for a network plan, if:
(i) there is no longer any enrollee under the group health plan who lives, resides, orworks in:
(A) the service area of the insurer; or
(B) the area for which the insurer is authorized to do business; and
(ii) in the case of the small employer market, the insurer applies the same criteria theinsurer would apply in denying enrollment in the plan under Subsection 31A-30-108(7); or
(b) for coverage made available in the small or large employer market only through anassociation, if:
(i) the employer's membership in the association ceases; and
(ii) the coverage is terminated uniformly without regard to any health status-relatedfactor relating to any covered individual.
(3) A health benefit plan for a plan sponsor may be discontinued if:
(a) a condition described in Subsection (2) exists;
(b) the plan sponsor fails to pay premiums or contributions in accordance with the termsof the contract;
(c) the plan sponsor:
(i) performs an act or practice that constitutes fraud; or
(ii) makes an intentional misrepresentation of material fact under the terms of thecoverage;
(d) the insurer:
(i) elects to discontinue offering a particular health benefit product delivered or issuedfor delivery in this state; and
(ii) (A) provides notice of the discontinuation in writing:
(I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
(II) at least 90 days before the date the coverage will be discontinued;
(B) provides notice of the discontinuation in writing:
(I) to the commissioner; and
(II) at least three working days prior to the date the notice is sent to the affected plansponsors, employees, and dependents of the plan sponsors or employees;
(C) offers to each plan sponsor, on a guaranteed issue basis, the option to purchase:
(I) all other health benefit products currently being offered by the insurer in the market;or
(II) in the case of a large employer, any other health benefit product currently beingoffered in that market; and
(D) in exercising the option to discontinue that product and in offering the option ofcoverage in this section, acts uniformly without regard to:
(I) the claims experience of a plan sponsor;
(II) any health status-related factor relating to any covered participant or beneficiary; or
(III) any health status-related factor relating to any new participant or beneficiary whomay become eligible for the coverage; or
(e) the insurer:
(i) elects to discontinue all of the insurer's health benefit plans in:
(A) the small employer market;
(B) the large employer market; or
(C) both the small employer and large employer markets; and
(ii) (A) provides notice of the discontinuation in writing:
(I) to each plan sponsor, employee, or dependent of a plan sponsor or an employee; and
(II) at least 180 days before the date the coverage will be discontinued;
(B) provides notice of the discontinuation in writing:
(I) to the commissioner in each state in which an affected insured individual is known toreside; and
(II) at least 30 working days prior to the date the notice is sent to the affected plansponsors, employees, and the dependents of the plan sponsors or employees;
(C) discontinues and nonrenews all plans issued or delivered for issuance in the market;and
(D) provides a plan of orderly withdrawal as required by Section 31A-4-115.
(4) A large employer health benefit plan may be discontinued or nonrenewed:
(a) if a condition described in Subsection (2) exists; or
(b) for noncompliance with the insurer's:
(i) minimum participation requirements; or
(ii) employer contribution requirements.
(5) A small employer health benefit plan may be discontinued or nonrenewed:
(a) if a condition described in Subsection (2) exists; or
(b) for noncompliance with the insurer's employer contribution requirements.
(6) A small employer health benefit plan may be nonrenewed:
(a) if a condition described in Subsection (2) exists; or
(b) for noncompliance with the insurer's minimum participation requirements.
(7) (a) Except as provided in Subsection (7)(d), an eligible employee may bediscontinued if after issuance of coverage the eligible employee:
(i) engages in an act or practice in connection with the coverage that constitutes fraud; or
(ii) makes an intentional misrepresentation of material fact in connection with thecoverage.
(b) An eligible employee that is discontinued under Subsection (7)(a) may reenroll:
(i) 12 months after the date of discontinuance; and
(ii) if the plan sponsor's coverage is in effect at the time the eligible employee applies toreenroll.
(c) At the time the eligible employee's coverage is discontinued under Subsection (7)(a),the insurer shall notify the eligible employee of the right to reenroll when coverage isdiscontinued.
(d) An eligible employee may not be discontinued under this Subsection (7) because of afraud or misrepresentation that relates to health status.
(8) For purposes of this section, a reference to "plan sponsor" includes a reference to the
employer:
(a) with respect to coverage provided to an employer member of the association; and
(b) if the health benefit plan is made available by an insurer in the employer market onlythrough:
(i) an association;
(ii) a trust; or
(iii) a discretionary group.
(9) An insurer may modify a health benefit plan for a plan sponsor only:
(a) at the time of coverage renewal; and
(b) if the modification is effective uniformly among all plans with that product.
Amended by Chapter 329, 2004 General Session