18 Del. Admin. Code § 1308-3.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1308-3.0 - Applicability and scope

3.1

3.1.1 Except as provided in sections 1.1 and 14.0, this Regulation shall apply to any health benefit plan, whether provided on a group or individual basis, which:

3.1.1.1 Meets the conditions set forth in 18 Del.C. § 7203;

3.1.1.2 Provides coverage to one or more employees of a small employer located in this state, without regard to whether the policy or certificate was issued in this state; and

3.1.1.3 Is in effect on or after the effective date of 18 Del.C. Ch. 72.

3.1.2 The provisions of 18 Del.C. Ch.72 and this Regulation shall not apply to an individual health insurance policy issued prior to the effective date of 18 Del.C. Ch. 72.

3.2

3.2.1 A carrier that provides individual health insurance policies to one or more of the employees of a small employer shall be considered a small employer carrier and shall be subject to the provisions of 18 Del.C. Ch. 72 and this Regulation with respect to such policies if the small employer contributes directly or indirectly to the premiums for the policies and the carrier is aware or should have been aware of such contributions.

3.2.2 In the case of a carrier that provides individual health insurance policies to one or more employees of a small employer, the small employer shall be considered to be an eligible small employer as defined in 18 Del.C. § 7207(a)(3) and the small employer carrier shall be subject to 18 Del.C. § 7207(a)(2) (relating to guaranteed issue of coverage) if:

3.2.2.1 The small employer has at least two (2) employees, and

3.2.2.2 The small employer contributes directly or indirectly to the premiums charged by the carrier, including, but not limited to the following conditions:

3.2.2.2.1 any portion of the premium or benefits is paid by or on behalf of the employee;

3.2.2.2.2 the health benefit plan is administered by the small employer;

3.2.2.2.3 an eligible employee or dependent is reimbursed, whether through wage adjustments or otherwise, by or on behalf of the small employer for any portion of the premium;

3.2.2.2.4 the health benefit plan is treated by the employer or any of the eligible employees or dependents as part of a plan or program for the purposes of Section 162, Section 125, or Section 106 of the United States Internal Revenue Code.

3.3 The provisions of 18 Del.C. Ch. 72 and this Regulation shall apply to a health benefit plan provided to a small employer or the employees of a small employer without regard to whether the health benefit plan is offered under or provided through a group policy or trust arrangement of any size sponsored by an association of discretionary group.

3.4 An individual health insurance policy shall not be subject to the provisions of 18 Del.C. Ch. 72 and this Regulation solely because the policyholder elects a deduction under Section 162(1) of the Internal Revenue Code.

3.5

3.5.1 If a small employer is issued a health benefit plan under the terms of 18 Del.C. Ch. 72, the provisions of 18 Del.C. Ch. 72 and this Regulation shall continue to apply to the health benefit plan in the case that the small employer subsequently employs more than twenty-five (25) eligible employees. A carrier providing coverage to such an employer shall, within sixty (60) days of becoming aware that the employer has more than twenty-five (25) eligible employees but no later than the anniversary date of the employer's health benefit plan, notify such employer that the protections provided under 18 Del.C. Ch. 72 and this Regulation shall cease to apply to the employer if such employer fails to renew its current health benefit plan or elects to enroll in a different health benefit plan.

3.5.2

3.5.2.1 If a health benefit plan is issued to an employer that is not a small employer as defined in 18 Del.C. Ch. 72, but subsequently the employer becomes a small employer (due to the loss or change of work status of one or more employees), the terms of 18 Del.C. Ch. 72 shall not apply to the health benefit plan. The carrier providing a health benefit plan to such an employer shall not become a small employer carrier under the terms of 18 Del.C. Ch. 72 solely because such carrier continues to provide coverage under the health benefit plan to the employer.

3.5.2.2 A carrier providing coverage to an employer described in section 3.5.2.1 shall, within sixty (60) days of becoming aware that the employer has twenty-five (25) or fewer eligible employees, notify such employer of the options and protections available to the employer under 18 Del.C. Ch. 72, including the employer's option to purchase a small employer health benefit plan from any small employer carrier.

3.6

3.6.1

3.6.1.1 If a small employer has employees in more than one state, the provisions of 18 Del.C. Ch. 72 and this Regulation shall apply to a health benefit plan issued to the small employer if:

3.6.1.1.1 the majority of eligible employees of such small employer are employed in this state; or

3.6.1.1.2 if no state contains a majority of the eligible employees of such small employer, the primary business location of the small employer is in this state.

3.6.1.2 In determining whether the laws of this state or another state apply to a health benefit plan issued to a small employer described in section 3.6.1.1, the provisions of such paragraph shall be applied as of the date the health benefit plan was issued to the small employer for the period that such health benefit plan remains in effect.

3.6.2 If a health benefit plan is subject to 18 Del.C. Ch. 72 and this Regulation, the provisions of 18 Del.C. Ch. 72 and this Regulation shall apply to all individuals covered under such health benefit plan, whether they reside in this state or in another state.

3.7 A carrier that is not operating as a small employer carrier in this state shall not become subject to the provisions of 18 Del.C. Ch. 72 and this regulation solely because a small employer that was issued a health benefit plan in another state by such carrier moves to this state.

18 Del. Admin. Code § 1308-3.0