Nebraska Statutes 44-5259. Health benefit plan; renewable; exceptions; small employer carrier; requirements
(1) A health benefit plan subject to the Small Employer Health Insurance Availability Act shall be renewable with respect to all eligible employees or dependents, at the option of the small employer, except in any of the following cases:
Terms Used In Nebraska Statutes 44-5259
- Director: shall mean the Director of Insurance. See Nebraska Statutes 44-5239
- Established geographic service area: shall mean a geographic area, as approved by the director and based on the carrier's certificate of authority to transact insurance business in this state, within which the carrier is authorized to provide coverage. See Nebraska Statutes 44-5241
- Fraud: Intentional deception resulting in injury to another.
- Health benefit plan: shall mean any hospital or medical policy or certificate, major medical expense insurance, or health maintenance organization subscriber contract. See Nebraska Statutes 44-5242
- Health-status-related factor: shall mean any of the following factors:
(1) Health status. See Nebraska Statutes 44-5242.02
- Network plan: shall mean health insurance coverage offered by a health carrier under which the financing and delivery of medical care including items and services paid for as medical care are provided, in whole or in part, through a defined set of providers under contract with the health carrier. See Nebraska Statutes 44-5244.02
- Person: shall include bodies politic and corporate, societies, communities, the public generally, individuals, partnerships, limited liability companies, joint-stock companies, and associations. See Nebraska Statutes 49-801
- Premium: shall mean all money 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 Nebraska Statutes 44-5247
- Small employer: shall mean any person, political subdivision, firm, corporation, limited liability company, partnership, or association that is actively engaged in business that, on at least fifty percent of its working days during the preceding calendar quarter, employed at least two and no more than fifty eligible employees, the majority of whom were employed within this state. See Nebraska Statutes 44-5253
- Small employer carrier: shall mean a carrier that offers health benefit plans covering eligible employees of one or more small employers in this state. See Nebraska Statutes 44-5254
- State: when applied to different states of the United States shall be construed to extend to and include the District of Columbia and the several territories organized by Congress. See Nebraska Statutes 49-801
(a) The small employer has failed to pay premiums or contributions in accordance with the terms of the health benefit plan or the health carrier has not received timely premium payments;
(b)(i) Fraud or misrepresentation of the small employer or, with respect to coverage of individual insureds, the insureds, or their representatives; or
(ii) The small employer has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage;
(c) Noncompliance with the small employer carrier‘s minimum participation requirements;
(d) Noncompliance with the small employer carrier’s employer contribution requirements;
(e) A decision by the small employer carrier to discontinue offering a particular type of group health benefit plan in the state‘s small employer market. A type of health benefit plan may be discontinued by the small employer carrier in that market only if the small employer carrier:
(i) Provides advance notice of its decision to the commissioner of insurance in each state in which it is licensed;
(ii) Provides notice of the decision not to renew coverage to all affected small employers, participants, and beneficiaries, and to the commissioner of insurance in each state in which an affected insured individual is known to reside, at least one hundred eighty days prior to the nonrenewal of any health benefit plans by the small employer carrier. Notice to the director shall be provided at least three working days prior to the notice to the affected small employers, participants, and beneficiaries;
(iii) Offers to each small employer provided the type of group health benefit plan the option to purchase all other health benefit plans currently being offered by the small employer carrier to small employers in the state; and
(iv) In exercising the option to discontinue the particular type of group health benefit plan and in offering the option of coverage under subdivision (1)(e)(iii) of this section, acts uniformly without regard to the claims experience of those small employers or any health-status-related factor relating to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for such coverage;
(f) A decision by the small employer carrier to discontinue offering and to nonrenew all its health benefit plans delivered or issued for delivery to small employers in this state. In such a case the small employer carrier shall:
(i) Provide advance notice of its decision to the commissioner of insurance in each state in which it is licensed;
(ii) Provide notice of the decision not to renew coverage to all affected small employers, participants, and beneficiaries, and to the commissioner of insurance in each state in which an affected insured individual is known to reside, at least one hundred eighty days prior to the nonrenewal of any health benefit plans by the small employer carrier. Notice to the director shall be provided at least three working days prior to the notice to the affected small employers, participants, and beneficiaries; and
(iii) Discontinue all health insurance issued or delivered for issuance in the state’s small employer market and not renew coverage under any health benefit plan issued to a small employer; and
(g) The director finds that the continuation of the coverage would:
(i) Not be in the best interests of the policyholders or certificate holders; or
(ii) Impair the carrier’s ability to meet its contractual obligations.
In such instance the director shall assist affected small employers in finding replacement coverage.
(2) A small employer carrier that elects not to renew a health benefit plan shall be prohibited from writing new business in the small employer market in this state for a period of five years from the date of notice to the director.
(3) In the case of a small employer carrier doing business in one established geographic service area of the state, the rules set forth in this section shall apply only to the carrier’s operations in that service area.
(4) A small employer carrier offering coverage through a network plan shall not be required to offer coverage or accept applications pursuant to subsection (1) or (2) of this section in the case of the following:
(a) To an eligible person who no longer resides, lives, or works in the service area of the small employer carrier or in an area for which the small employer carrier is authorized to do business, but only if coverage is terminated under this section uniformly without regard to any health-status-related factor of covered individuals; or
(b) To a small employer that no longer has any enrollee in connection with such plan who lives, resides, or works in the service area of the small employer carrier or the area for which the small employer carrier is authorized to do business.