Okla. Admin. Code § 365:10-5-163

Current through Vol. 42, No. 7, December 16, 2024

Section 365:10-5-163 - Restoration of coverage

(a)Offer required and exceptions.

(1) Except as provided in 365:10-5-163(a)(2), a small employer carrier shall, as a condition of continuing to transact business in this state with small employers, offer to provide health benefit plan as described in 365:10-5-163(c) to any small employer whose coverage was terminated or not renewed by such small employer carrier after January 1,1995.

(2) The offer required under 365:10-5-163(a)(1) shall not be required with respect to a health benefit plan that was not renewed if:

(A) The health benefit plans were not renewed for reasons permitted in 36 O.S.Supp.1994, §6516(A), or

(B) The nonrenewal was a result of the small employer voluntarily electing coverage under a different health benefit plan.

(b) The offer made under 365:10-5-163(a) shall occur not later than thirty (30) days after a carrier indicates its intention to operate as a small employer carrier in this state pursuant to 36 O.S.Supp.1994, §6520. A small employer shall be given at least sixty (60) days to accept an offer made pursuant to 365:10-5-163(a).

(c) A health benefit plan provided to a terminated small employer pursuant to 365:10-5-163(a) shall meet the following conditions:

(1) The health benefit plan shall contain benefits that are identical to the benefits in the health benefit plan that was terminated or nonrenewed.

(2) The health benefit plan shall not be subject to any waiting periods (including exclusion periods for preexisting conditions) or other limitations on coverage that exceed those limitations contained in the health benefit plan that was terminated or nonrenewed. In applying such exclusions or limitations, the health benefit plan shall be treated as if it were continuously in force from the date it was originally issued to the date that it is restored pursuant to 365:10-5-163 and 36 O.S.Supp.1994, §6528.

(3) The health benefit plan shall not be subject to any provision that restricts or excludes coverage or benefits for specific diseases, medical conditions or services otherwise covered by the plan.

(4) The health benefit plan shall provide coverage to all employees who are eligible employees as of the date the plan is restored. The carrier shall offer coverage to each dependent of such eligible employees.

(5) The premium rate for the health benefit plan shall be no more than the premium rate charged to the small employer on the date the health benefit plan was terminated or nonrenewed; provided that, if the number of case characteristics of the eligible employees (or their dependents) of the small employer has changed between the date the health benefit plan was terminated or nonrenewed and the date that it is restored, the carrier may adjust the premium rates to reflect any changes in case characteristics of the small employer. If the carrier has increased premium rates for other similar groups with similar coverage to reflect general increases in health care costs and utilization, the premium rate may further be adjusted to reflect the lowest such increase given to a similar group. The premium rate for the health benefit plan may not be increased to reflect any changes in risk characteristics of the small employer group until one year after the date of health benefit plan is restored. Any such increase shall be subject to the provisions of 36 O.S.Supp.1994, §6515.

(6) The health benefit plan shall not be eligible to be reinsured under the provisions of 36 O.S.Supp.1994, §6521, except that the carrier may reinsure new entrants to the health benefit plan who enroll after the restoration of coverage.

Okla. Admin. Code § 365:10-5-163

Added at 12 Ok Reg 3137, eff 7-31-95