Delaware Code Title 18 Sec. 7207 – Availability of coverage; preexisting conditions; minimum …
(a) (1) Subject to paragraph (a)(4) of this section, every small employer carrier shall, as a condition of transacting business in this State with small employers, actively offer to small employers at least 2 health benefit plans. One health benefit plan offered by each small employer carrier shall be a basic health benefit plan and 1 plan shall be a standard health benefit plan.
(2) a. A small employer carrier shall issue a basic health benefit plan or a standard health benefit plan to any small employer meeting the requirements of paragraph (a)(3) of this section that applies to either 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 chapter.
b. In the case of a small employer carrier that establishes more than 1 class of business pursuant to § 7204 of this title, the small employer carrier shall maintain and issue to such small employers at least 1 basic health benefit plan and at least 1 standard health benefit plan in each class of business so established. A small employer carrier may apply reasonable criteria in determining whether to accept a small employer into a class of business, provided that:
1. The criteria are not intended to discourage or prevent acceptance of small employers applying for a basic or standard health benefit plan;
2. The criteria are not related to the health status or claim experience of the small employer;
3. The criteria are applied consistently to all small employers applying for coverage in the class of business; and
4. The small employer carrier provides for the acceptance of all eligible small employers into 1 or more classes of business.
The provisions of this subparagraph shall not apply to a class of business into which the small employer carrier is no longer enrolling new small businesses.
(3) A small employer is eligible under paragraph (a)(2) of this section if it employed at least 1 or more eligible employees within this State on at least 50 percent of its working days during the preceding calendar quarter.
(4) The provisions of this section shall be effective 180 days after the Commissioner‘s and Delaware Health Care Commission’s approval of the basic health benefit plan and the standard health benefit plan developed pursuant to § 7211 of this title; provided, that if the Small Employer Health Reinsurance Program created pursuant to § 7210 of this title [repealed] is not yet operative on that date, the provisions of this paragraph shall be effective on the date that program begins operation.
Terms Used In Delaware Code Title 18 Sec. 7207
- Affiliation period: means a period of time not to exceed 2 months (3 months for late enrollees) during which a health maintenance organization does not collect premiums and coverage issued is not effective. See Delaware Code Title 18 Sec. 7202
- 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
- Bona fide association: means , with respect to health insurance coverage offered in Delaware, an association which:
- Carrier: means any entity that provides health insurance in this State. See Delaware Code Title 18 Sec. 7202
- Class of business: means all of a carrier's business unless more than 1 class is established pursuant to § 7204 of this title. See Delaware Code Title 18 Sec. 7202
- Commissioner: means the Insurance Commissioner of this State. See Delaware Code Title 18 Sec. 7202
- Dependent: A person dependent for support upon another.
- Dependent: means a spouse, a child under the age of 26 years, and an unmarried child of any age who is medically certified as totally disabled and dependent upon the parent. See Delaware Code Title 18 Sec. 7202
- Eligible employee: means an employee who works on a full-time basis and has a normal work week of 30 or more hours. See Delaware Code Title 18 Sec. 7202
- 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
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- 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
- Premium: means all moneys paid by a small employer and eligible employees as a condition of receiving coverage from a small employer carrier, including any fees or other contributions associated with the health benefit plan. 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
- qualifying existing coverage: means benefits or coverage provided under:
- 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
- Waiting period: means , with respect to a group health plan and an individual who is a potential participant in or beneficiary of the plan, the period that must pass with respect to the individual before the individual is eligible for benefits under the terms of the plan. See Delaware Code Title 18 Sec. 7202
(b) (1) A small employer carrier shall file with the Commissioner, in a format and manner prescribed by the Commissioner, the basic health benefit plans and the standard health benefit plans to be used by the carrier within 90 days after the Commissioner establishes the guidelines thereof. A health benefit plan filed pursuant to this paragraph may be used by a small employer carrier beginning 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 basic or standard health benefit plan on the grounds that the plan does not meet the requirements of this chapter.
(c) Health benefit plans covering small employers shall comply with the following provisions:
(1) A health benefit plan shall not deny, exclude or limit benefits for a covered individual for losses due to a preexisting condition.
(2) A health maintenance organization may impose an affiliation period. An affiliation period shall run concurrently with any waiting period imposed. Such a health maintenance organization may, in lieu of an affiliation period, use an alternative method to address adverse selection with the prior approval of the Insurance Commissioner.
(3) A health benefit plan shall waive any affiliation period with respect to particular services for the period of time an individual was previously covered by qualifying previous coverage that provided benefits with respect to such services provided, that the qualifying previous coverage was continuous to a date not more than 63 days prior to the effective date of the new coverage, excluding any waiting period applicable to the new plan. This paragraph does not preclude application of any waiting period applicable to all new enrollees under the health benefit plan.
(4) A health benefit plan may not exclude coverage for late enrollees for a preexisting condition.
(5) a. Except as provided in subsection (d) of this section, requirements used by a small employer carrier in determining whether to provide coverage to a small employer, including requirements for minimum participation of eligible employees, shall be applied uniformly among all small employers with the same number of eligible employees applying for coverage or receiving coverage from the small employer carrier.
b. A small employer carrier may vary the application of minimum participation requirements and minimum employer contribution requirements only by the size of the small employer group.
c. An employee who does not participate in the health benefit plan and who presents satisfactory evidence that the employee has coverage through a spouse or other qualifying existing coverage shall not be counted by a small employer carrier with respect to number or percent participation requirements.
d. A small employer carrier shall not increase any requirement for minimum employee participation or any requirement for minimum employer contribution applicable to a small employer at any time after the small employer has contracted for coverage.
(6) 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 in a small employer group or to only part of the group, except in the case of late enrollees as provided in paragraph (c)(4) of this section.
b. A small employer carrier shall not modify a basic or standard 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 for certain diseases or medical conditions otherwise covered by the health benefit plan.
(d) (1) A small employer carrier shall not be required to offer coverage or accept applications pursuant to subsection (a) of this section in the case 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; or
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 (d)(1)c. of this section may not offer coverage in the applicable area to new cases of employer groups with 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 its employers pursuant to subsection (a) of this section 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) of this section would place the small employer carrier in a financially impaired condition.
(f) Effective July 1, 1997, every small employer carrier shall also offer to small employers a choice of all the other small group plans the carrier markets in Delaware; except that this requirement shall not apply to:
(1) A health benefit plan offered by a carrier if such plan is made available in the small group market only through 1 or more bona fide association plans; or
(2) A business group of 1 where the business group of 1 does not meet the carrier’s actuarially-based underwriting criteria.
(g) A health benefit plan shall not establish rules for eligibility for any individual to enroll under the plan based on any health status-related factors in relation to the individual or a dependent of the individual.
68 Del. Laws, c. 340, § ?1; 69 Del. Laws, c. 403, §§ ?3-5; 70 Del. Laws, c. 186, § ?1; 71 Del. Laws, c. 143, §§ ?8-12; 72 Del. Laws, c. 383, §§ ?1, 2; 79 Del. Laws, c. 99, § ?15;