Ala. Admin. Code r. 482-1-116-.07
Current through Register Vol. 43, No. 1, October 31, 2024
Section 482-1-116-.07 - Availability Of Coverage(a)(1) Every small employer carrier shall, as a condition of transacting business in this state with small employers, actively offer to small employers all health benefit plans it actively markets to small employers in this state. A small employer carrier shall be considered to be actively marketing a health benefit plan if it offers that plan to any small employer not currently receiving a health benefit plan by such small employer carrier.(2) Subject to Subdivision (1), a small employer carrier shall issue any health benefit plan to any eligible small employer that applies for such plan and agrees to make the required premium payments and to satisfy the other reasonable provisions of the health benefit plan not inconsistent with this Regulation.(b)(1) A small employer carrier shall file with the commissioner, in a format and manner prescribed by the commissioner, the health benefit plans to be used by the carrier. A health benefit plan filed pursuant to this requirement may be used by a small employer carrier beginning thirty (30) days after it is filed unless the commissioner disapproves its use.(2) The commissioner at any time may, after providing notice and an opportunity for a hearing to the small employer carrier, disapprove the continued use by a small employer carrier of a health benefit plan on the grounds that the plan does not meet the requirements of this Regulation.(c) Health benefit plans covering small employers shall comply with all of the following provisions: (1) A health benefit plan shall not deny, exclude or limit benefits for a covered individual for losses incurred more than twelve (12) months following the effective date of the individual's coverage due to a preexisting condition. A health benefit plan shall not define a preexisting condition more restrictively than a condition for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the effective date of coverage. For purposes of this subsection, pregnancy may not be considered a preexisting condition under a health benefit plan and no preexisting condition shall apply to a dependent newborn or adopted child if covered within 30 days of birth or adoption.(2) A small employer carrier shall waive any carrier waiting period applicable to a preexisting condition exclusion or limitation period with respect to particular services in a health benefit plan for the period of time an individual was previously covered by qualifying previous coverage provided that the qualifying previous coverage was continuous to a date not more than sixty-three (63) days prior to the effective date of new coverage. The period of continuous coverage shall not include any waiting period for the effective date of the new coverage applied by the employer or the carrier, or for the normal application and enrollment process following employment or other triggering event for eligibility. A carrier that does not use preexisting condition limitations in any of its health benefit plans may impose an affiliation period. "Affiliation period" means a period of time not to exceed sixty (60) days for new entrants and not to exceed ninety (90) days for late enrollees during which no premiums shall be collected and coverage issued would not become effective. This Subdivision does not preclude application of any waiting period applicable to all new enrollees under the health benefit plan, provided that any carrier-imposed waiting period be no longer than sixty (60) days and be used in lieu of a preexisting condition exclusion.(3) A health benefit plan may exclude coverage for late enrollees for preexisting conditions for a period not to exceed eighteen (18) months.(4)a. Except as provided in this subsection, requirements used by a small employer carrier in determining whether to provide coverage to a small employer shall be applied uniformly among all small employers applying for coverage or receiving coverage from the small employer carrier.b. A small employer carrier shall not require a minimum participation level greater than: 1. One hundred percent (100%) of eligible employees working for groups of three (3) or less employees; and2. Seventy-five percent (75%) of eligible employees working for groups with more than three (3) employees.c. In applying minimum participation requirements with respect to a small employer, a small employer carrier shall not consider employees or dependents who have qualifying existing coverage in determining whether the applicable percentage of participation is met.d. A small employer carrier shall not increase any requirement for minimum employee participation or modify any requirement for minimum employer contribution applicable to a small employer at any time after the small employer has been accepted for coverage.(5)a. If a small employer carrier offers coverage to a small employer, the small employer carrier shall offer coverage to all of the eligible employees of a small employer and their dependents. A small employer carrier shall not offer coverage to only certain individuals or dependents in a small employer group or to only part of the group.b. Except as permitted under Subdivisions (1) and (3) of this subsection, a small employer carrier shall not modify a health benefit plan with respect to a small employer or any eligible employee or dependent, through riders, endorsements or otherwise, to restrict or exclude coverage or benefits for specific diseases, medical conditions or services otherwise covered by the plan.(d)(1) A small employer carrier shall not be required to offer coverage or accept applications pursuant to Subsection (a) in the case of any of the following: a. To a small employer, where the small employer is not physically located in the carrier's established geographic service area.b. To an employee, when the employee does not work or reside within the carrier's established geographic service area.c. Within an area where the small employer carrier reasonably anticipates, and demonstrates to the satisfaction of the commissioner, that it will not have the capacity within its established geographic service area to deliver service adequately to the members of such groups because of its obligations to existing group policyholders and enrollees.(2) A small employer carrier that cannot offer coverage pursuant to Paragraph c. of Subdivision (1) may not offer coverage in the applicable area to new cases of employer groups with less than two or more than 50 eligible employees or to any small employer groups until the later of 180 days following each such refusal or the date on which the carrier notifies the commissioner that it has regained capacity to deliver services to small employer groups.(e) A small employer carrier shall not be required to provide coverage to small employers pursuant to Subsection (a) for any period of time for which the Commissioner determines that requiring the acceptance of small employers in accordance with the provisions of Subsection (a) would place the carrier in a financially impaired condition. Author: Reyn Norman, Associate Counsel
Ala. Admin. Code r. 482-1-116-.07
New Rule: September 3, 1997; effective September 28, 1997. Amended: October 14, 1999; effective January 1, 2000. Amended: September 12, 2001; effective October 1, 2001. Filed with LRS September 14, 2001. Rule is not subject to the Alabama Administrative Procedure Act.Statutory Authority:Code of Ala. 1975, § 27-52-21.