Nebraska Statutes 44-5266. Small employer carrier; market health benefit plan coverage; carrier, agent, or broker; prohibited activities; compensation to agent or broker; denial of application; rules and regulations; unfair trade practice; when; thir…
(1) Each small employer carrier shall actively market health benefit plan coverage, including the basic health benefit plans 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 Nebraska Statutes 44-5266
- Basic health benefit plan: shall mean a lower cost health benefit plan regulated by the Department of Insurance. See Nebraska Statutes 44-5230
- Contract: A legal written agreement that becomes binding when signed.
- 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
- 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
- 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
- Restricted network provision: shall mean 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 contractual arrangement with the carrier to provide health care services to covered individuals. See Nebraska Statutes 44-5252
- 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
- Standard health benefit plan: shall mean a health benefit plan regulated by the Department of Insurance. See Nebraska Statutes 44-5255
- 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
(2)(a) Except as provided in subdivision (b) of this subsection, no small employer carrier, agent, or broker shall, directly or indirectly, engage in the following activities:
(i) 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; or
(ii) 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.
(b) The provisions of subdivision (a) of this subsection shall not apply with respect to information provided by a small employer carrier, an agent, or a broker to a small employer regarding the established geographic service area or a restricted network provision of a small employer carrier.
(3)(a) Except as provided in subdivision (b) of this subsection, no small employer carrier shall, directly or indirectly, enter into any contract, agreement, or arrangement with an agent or broker that provides for or results in the compensation paid to an agent or broker for the sale of a health benefit plan to be varied because of the health status, claims experience, industry, occupation, or geographic location of the small employer.
(b) The provisions of subdivision (a) of this subsection shall not apply with respect to a compensation arrangement that provides compensation to an agent or broker on the basis of percentage of premium except that the percentage shall not vary because of the health status, claims experience, industry, occupation, or geographic area of the small employer.
(4) A small employer carrier shall provide reasonable compensation to an agent or broker, if any, for the sale of a basic health benefit plan or a standard health benefit plan.
(5) No small employer carrier, agent, or broker 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.
(6) 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.
(7) The director may establish rules and regulations setting forth additional standards to provide for the fair marketing and broad availability of health benefit plans to small employers in this state.
(8)(a) A violation of this section by a small employer carrier, an agent, or a broker shall be an unfair trade practice in the business of insurance under the Unfair Insurance Trade Practices Act.
(b) If a small employer carrier enters into a contract, agreement, or other arrangement with a third-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.