Delaware Code Title 18 Sec. 7215 – Standards to assure fair marketing
(a) Each small employer carrier shall actively market health benefit plan coverage, including the basic and standard health benefit plans, to eligible small employers in the State. If a small employer carrier denies coverage to a small employer on the basis of the health status or claims experience of the small employer or its employees or dependents, the small employer carrier shall offer the small employer the opportunity to purchase a basic health benefit plan and a standard health benefit plan.
Terms Used In Delaware Code Title 18 Sec. 7215
- Basic health benefit plan: means a lower cost health benefit plan developed pursuant to § 7211 of this title. See Delaware Code Title 18 Sec. 7202
- Carrier: means any entity that provides health insurance in this State. See Delaware Code Title 18 Sec. 7202
- Commissioner: means the Insurance Commissioner of this State. See Delaware Code Title 18 Sec. 7202
- Contract: A legal written agreement that becomes binding when signed.
- Established geographic service area: means a geographic area, as approved by the Commissioner and based on the carrier's certificate of authority to transact insurance in this State, within which the carrier is authorized to provide coverage. See Delaware Code Title 18 Sec. 7202
- Health benefit plan: means any hospital or medical expense policy or certificate, hospital or medical service corporation contract, health maintenance organization or health service corporation subscriber contract or any other similar health contract, including a high deductible medical expense policy used in conjunction with a medical savings account, subject to the jurisdiction of the Commissioner available for use, offered or sold to an individual in the State of Delaware. See Delaware Code Title 18 Sec. 7202
- Plan of operation: means the plan of operation of the program established pursuant to § 7210 of this title [repealed]. See Delaware Code Title 18 Sec. 7202
- Producer: means agent and/or broker. See Delaware Code Title 18 Sec. 7202
- Program: means the Delaware Small Employer Reinsurance Program created by § 7210 of this title [repealed]. See Delaware Code Title 18 Sec. 7202
- Restricted network provision: means any provision of a health benefit plan that conditions the payment of benefits, in whole or in part, on the use of health-care providers that have entered into a contractual arrangement with the carrier pursuant to Chapter 64 of this title or otherwise to provide health-care services to covered individuals. See Delaware Code Title 18 Sec. 7202
- Small employer: means any person, firm, corporation, partnership or association that is actively engaged in business that, on at least 50% of its working days during the preceding calendar quarter, employed no more than 50 eligible employees, the majority of whom were employed within this State. See Delaware Code Title 18 Sec. 7202
- Small employer carrier: means a carrier that offers health benefit plans covering eligible employees of 1 or more small employers in this State. See Delaware Code Title 18 Sec. 7202
- Standard health benefit plan: means a health benefit plan developed pursuant to § 7211 of this title. See Delaware Code Title 18 Sec. 7202
- 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
(b) (1) Except as provided in paragraph (b)(2) of this section, no small employer carrier or producer shall, directly or indirectly, engage in the following activities:
a. Encouraging or directing small employers to refrain from filing an application for coverage with the small employer carrier because of the health status, claims experience, industry, occupation or geographic location of the small employer.
b. Encouraging or directing small employers to seek coverage from another carrier because of the health status, claims experience, industry, occupation or geographic location of the small employer.
(2) The provision of paragraph (b)(1) of this section shall not apply with respect to information provided by a small employer carrier or producer to a small employer regarding the established geographic service area or a restricted network provision of a small employer carrier.
(c) Except as provided in this section, no small employer carrier shall, directly or indirectly, enter into any contract, agreement or arrangement with a producer that provides for or results in the compensation paid to a producer for the sale of a health benefit plan to be varied because of the health status, claims experience, industry, occupation or geographic area of the small employer.
(d) A small employer carrier shall provide reasonable compensation, as provided under the plan of operation of the Program, to a producer, if any, for the sale of a basic or standard health benefit plan.
(e) No small employer carrier may terminate, fail to renew or limit its contract or agreement of representation with a producer for any reason related to the health status, claims experience, occupation or geographic location of the small employers placed by the producer with the small employer carrier.
(f) No small employer carrier or producer may induce or otherwise encourage a small employer to separate or otherwise exclude an employee from health coverage or benefits provided in connection with the employee’s employment.
(g) Denial by a small employer carrier of an application for coverage from a small employer shall be in writing and shall state the reason or reasons for the denial.
(h) The Commissioner may establish regulations setting forth additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers in this State.
(i) (1) A violation of this section by a small employer carrier or a producer shall be an unfair trade practice under §§ 2303 and 2304 of this title.
(2) If a small employer carrier enters into a contract, agreement or other arrangement with a thirrd-party administrator to provide administrative, marketing or other services related to the offering of health benefit plans to small employers in this State, the third-party administrator shall be subject to this section as if it were a small employer carrier.