Delaware Code Title 18 Sec. 3571J – Guaranteed availability of coverage
(a) Guaranteed availability of coverage in the group market. — Subject to subsections (b)-(d) of this section, a health insurer that offers health insurance coverage in the group market in this State must offer to any employer in this State all products that are approved for sale in the group market, and must accept any employer that applies for any of those products.
Terms Used In Delaware Code Title 18 Sec. 3571J
- Contract: A legal written agreement that becomes binding when signed.
- Month: means a calendar month, unless otherwise expressed. See Delaware Code Title 1 Sec. 302
- State: means the State of Delaware; and when applied to different parts of the United States, it includes the District of Columbia and the several territories and possessions of the United States. See Delaware Code Title 1 Sec. 302
- Year: means a calendar year, and is equivalent to the words "year of our Lord. See Delaware Code Title 1 Sec. 302
(b) Enrollment periods. — A health insurer may restrict enrollment in health insurance coverage to open or special enrollment periods.
(1) a. Open enrollment periods in the group market. —
A health insurer in the group market must permit an employer to purchase health insurance coverage for a group health plan at any point during the year. In the case of health insurance coverage offered in the small group market, a health insurer may decline to offer coverage to a plan sponsor that is unable to comply with a material plan provision relating to employer contribution or group participation rules under applicable state law and, in the case of a qualified health plan offered in the Small Business Health Options Program (SHOP), as permitted by 45 C.F.R. § 156.285(c). For purposes of this paragraph (b)(1):
1. “Employer contribution rule” means a requirement relating to the minimum level or amount of employer contribution toward the premium for enrollment of participants and beneficiaries.
2. “Group participation rule” means a requirement relating to the minimum number of participants or beneficiaries that must be enrolled in relation to a specific percentage or number of eligible individuals or employees of an employer.
b. With respect to coverage in the small group market, and in the large group market if such coverage is offered in a SHOP in the State, coverage for a group enrollment received from a qualified employer at the time of an initial group enrollment or renewal becomes effective as follows:
1. Between the first and fifteenth day of any month, the health insurer or SHOP must ensure a coverage effective date of the first day of the following month unless the employer opts for a later effective date within a quarter for which small group market rates are available.
2. Between the sixteenth and last day of any month, the health insurer or SHOP must ensure a coverage effective date of the first day of the second following month unless the employer opts for a later effective date within a quarter for which small group market rates are available.
(2) Special enrollment periods. —
A health insurer in the group market shall establish special enrollment periods for qualifying events as defined under § 603 of the Employee Retirement Income Security Act of 1974 [29 U.S.C. § 1163], as amended. Enrollees must be provided 30 calendar days after the date of the qualifying event to elect coverage, with such coverage becoming effective consistent with the dates described in 45 C.F.R. § 155.420(b), as in effect on January 1, 2018. These special enrollment periods are in addition to any other special enrollment periods that are required under federal and state law.
(c) Special rules for network plans. — (1) In the case of a health insurer that offers health insurance coverage in the group market through a network plan, the health insurer may do the following:
a. Limit the employers that may apply for the coverage to those with eligible individuals in the group market who live, work or reside in the service area for the network plan.
b. Within the service area of the plan, deny coverage to employers if the carrier has demonstrated to the Commissioner the following:
1. It will not have the capacity to deliver services adequately to enrollees of any additional groups because of its obligations to existing group contract holders and enrollees.
2. It is applying paragraph (c)(1) of this section uniformly to all employers without regard to the claims experience of those employers and their employees (and their dependents) or any health-status related factor relating to such employees and dependents.
(2) A health insurer that denies health insurance coverage to an employer in any service area, in accordance with paragraph (c)(1)b. of this section, may not offer coverage in the group market within the service area to any employer for a period of 180 calendar days after the date the coverage is denied. This paragraph (c)(2) does not limit the health insurer’s ability to renew coverage already in force or relieve the carrier of the responsibility to renew that coverage.
(3) Coverage offered within a service area after the 180-day period specified in paragraph (c)(2) of this section is subject to the requirements of this section.
(d) Application of financial capacity limits. — (1) A health insurer may deny health insurance coverage in the group market if the health insurer has demonstrated to the Commissioner the following:
a. It does not have the financial reserves necessary to underwrite additional coverage.
b. It is applying this paragraph (d)(1) uniformly to all employers in the group market in this State consistent with applicable state law and without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such employees and dependents.
(2) A health insurer that denies health insurance coverage to any employer in this State under paragraph (d)(1) of this section may not offer coverage in the group market in this State before the later of either of the following dates:
a. The one hundred and eighty-first day after the date the health insurer denies coverage;
b. The date the health insurer demonstrates to the Commissioner that the carrier has sufficient reserves to underwrite additional coverage.
(3) Paragraph (d)(2) of this section does not limit the carrier’s ability to renew coverage already in force or relieve the carrier of the responsibility to renew that coverage.
(4) Coverage offered after the 180-day period specified in paragraph (d)(2) of this section is subject to the requirements of this section.
(5) The Commissioner may provide for the application of this subsection (d) on service-area-specific basis.
(e) Marketing. — A health insurer and its officials, employees, agents and representatives must comply with any applicable state laws and regulations regarding marketing by health insurers and cannot employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs in health insurance coverage.
(f) Grandfathered health plans. — This section does not apply to grandfathered health plans. For purposes of this section, “grandfathered health plans” means plans provided by a health insurer in which an individual was enrolled on March 23, 2010, for as long as it maintains that status in accordance with federal regulations.