(a)  Subject to subsections (b) through (i) of this section, all health insurance carriers that offer health insurance coverage in the individual market in this state shall provide for the guaranteed availability of coverage to any eligible applicant. For the purposes of this section, an “eligible applicant” means any individual resident of this state. A carrier offering health insurance coverage in the individual market shall offer to any eligible applicant in the state all health insurance coverage plans of that carrier that are approved for sale in the individual market and shall accept any eligible applicant that applies for coverage under those plans. A carrier may not:

(1)  Decline to offer the coverage to, or deny enrollment of, the individual; or

(2)  Impose any preexisting condition exclusion with respect to the coverage.

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Terms Used In Rhode Island General Laws 27-18.5-3

  • carrier: means any entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the director, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services, including, without limitation, an insurance company offering accident and sickness insurance, a health maintenance organization, a nonprofit hospital, medical or dental service corporation, or any other entity providing a plan of health insurance or health benefits by which healthcare services are paid or financed for an eligible individual or his or her dependents by such entity on the basis of a periodic premium, paid directly or through an association, trust, or other intermediary, and issued, renewed, or delivered within or without Rhode Island to cover a natural person who is a resident of this state, including a certificate issued to a natural person that evidences coverage under a policy or contract issued to a trust or association;

    (9)(i)  "Health insurance coverage" means a policy, contract, certificate, or agreement offered by a health insurance carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of healthcare services. See Rhode Island General Laws 27-18.5-2

  • Commissioner: means the health insurance commissioner;

    (4)  "Creditable coverage" has the same meaning as defined in the United States Public Health Service Act, Section 2701(c), Rhode Island General Laws 27-18.5-2

  • Contract: A legal written agreement that becomes binding when signed.
  • Health status-related factor: means any of the following factors:

    (i)  Health status;

    (ii)  Medical condition, including both physical and mental illnesses;

    (iii)  Claims experience;

    (iv)  Receipt of health care;

    (v)  Medical history;

    (vi)  Genetic information;

    (vii)  Evidence of insurability, including conditions arising out of acts of domestic violence; and

    (viii)  Disability;

    (11)  "High-risk individuals" means those individuals who do not pass medical underwriting standards due to high healthcare needs or risks;

    (12)  "Individual market" means the market for health insurance coverage offered to individuals other than in connection with a group health plan;

    (13)  "Network plan" means health insurance coverage offered by a health insurance 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 carrier;

    (14)  "Preexisting condition" means, with respect to health insurance coverage, a condition (whether physical or mental), regardless of the cause of the condition, that was present before the date of enrollment for the coverage, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month (6) period ending on the enrollment date. See Rhode Island General Laws 27-18.5-2

  • Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.

(b)  All health insurance carriers that offer health insurance coverage in the individual market in this state shall offer all policy forms of health insurance coverage to all eligible applicants. Provided, a carrier may offer plans with reduced cost sharing for qualifying eligible applicants, based on available federal funds including those described by 42 U.S.C. § 18071, or based on a program established with state funds.

(c)(1)  A carrier may deny health insurance coverage in the individual market to an eligible applicant if the carrier has demonstrated to the commissioner that:

(i)  It does not have the financial reserves necessary to underwrite additional coverage; and

(ii)  It is applying this subsection uniformly to all individuals in the individual market in this state consistent with applicable state law and without regard to any health status-related factor of the individuals.

(2)  A carrier upon denying individual health insurance coverage in this state in accordance with this subsection may not offer that coverage in the individual market in this state for a period of one hundred eighty (180) days after the date the coverage is denied or until the carrier has demonstrated to the commissioner that the carrier has sufficient financial reserves to underwrite additional coverage, whichever is later.

(d)  Nothing in this section shall be construed to require that a carrier offering health insurance coverage only in connection with group health plans or through one or more bona fide associations, or both, offer health insurance coverage in the individual market.

(e)  A carrier offering health insurance coverage in connection with group health plans under this title shall not be deemed to be a health insurance carrier offering individual health insurance coverage solely because the carrier offers a conversion policy.

(f)  Except for any high risk pool rating rules to be established by the office of the health insurance commissioner (OHIC) as described in this section, nothing in this section shall be construed to create additional restrictions on the amount of premium rates that a carrier may charge an individual for health insurance coverage provided in the individual market; or to prevent a health insurance carrier offering health insurance coverage in the individual market from establishing premium rates or modifying applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.

(g)  OHIC may pursue federal funding in support of the development of a high risk pool for the individual market, as defined in § 27-18.5-2, contingent upon a thorough assessment of any financial obligation of the state related to the receipt of said federal funding being presented to, and approved by, the general assembly by passage of concurrent general assembly resolution. The components of the high risk pool program, including, but not limited to, rating rules, eligibility requirements, and administrative processes, shall be designed in accordance with section 2745 of the Public Health Service Act (42 U.S.C. § 300gg-45), also known as the State High Risk Pool Funding Extension Act of 2006, and defined in regulations promulgated by the office of the health insurance commissioner on or before October 1, 2007.

(h)(1)  In the case of a health insurance carrier that offers health insurance coverage in the individual market through a network plan, the carrier may limit the individuals who may be enrolled under that coverage to those who live, reside, or work within the service areas for the network plan; and within the service areas of the plan, deny coverage to individuals if the carrier has demonstrated to the commissioner that:

(i)  It will not have the capacity to deliver services adequately to additional individual enrollees because of its obligations to existing group contract holders and enrollees and individual enrollees; and

(ii)  It is applying this subsection uniformly to individuals without regard to any health status-related factor of the individuals and without regard to whether the individuals are eligible individuals.

(2)  Upon denying health insurance coverage in any service area in accordance with the terms of this subsection, a carrier may not offer coverage in the individual market within the service area for a period of one hundred eighty (180) days after the coverage is denied.

(i)  A carrier must allow an eligible applicant to enroll in coverage during:

(1)  An open enrollment period to be established by the commissioner and held annually for a period of between thirty (30) and sixty (60) days;

(2)  Special enrollment periods as established in accordance with the version of 45 C.F.R. § 147.104 in effect on January 1, 2023; and

(3)  Any other open enrollment periods or special enrollment periods established by federal or state law, rule, or regulation.

History of Section.
P.L. 2000, ch. 200, § 4; P.L. 2000, ch. 229, § 4; P.L. 2001, ch. 241, § 1; P.L. 2001, ch. 331, § 1; P.L. 2006, ch. 271, § 1; P.L. 2006, ch. 283, § 1; P.L. 2023, ch. 214, § 1, effective June 21, 2023; P.L. 2023, ch. 215, § 1, effective June 21, 2023.