42 U.S.C. § 300gg–1: Guaranteed availability…

Summary

Health insurance companies that sell individual or group plans in a State must accept every employer and person who applies for coverage, unless the rules below let them limit who can enroll. Companies can make people sign up only during open enrollment or during special enrollment periods. They must set up special enrollment periods for qualifying events under section 1163 of title 29, and a federal official will write rules about these enrollment periods. For plans that use a provider network, an insurer can limit applicants to people who live, work, or live in the plan’s service area. An insurer may refuse new groups or people in that area if it proves to the State that it cannot serve more enrollees and that the refusal is applied equally to everyone, without using past claims or health status. If an insurer denies coverage for these reasons, it cannot sell coverage in that service area for 180 days. An insurer can also deny coverage if it shows it lacks the financial reserves to add more members and applies that rule evenly; after such a denial it may not sell coverage in the State for 180 days or until it proves it has enough reserves, whichever is later.

Title 42, §300gg–1

The Public Health and Welfare, Source: USLM XML via OLRC

(a)Guaranteed issuance of coverage in the individual and group market

Subject to subsections (b) through (e), each health insurance issuer that offers health insurance coverage in the individual or group market in a State must accept every employer and individual in the State that applies for such coverage.

(b)Enrollment

(1)Restriction

A health insurance issuer described in subsection (a) may restrict enrollment in coverage described in such subsection to open or special enrollment periods.

(2)Establishment

A health insurance issuer described in subsection (a) shall, in accordance with the regulations promulgated under paragraph (3), establish special enrollment periods for qualifying events (under section 1163 of title 29).

(3)Regulations

The Secretary shall promulgate regulations with respect to enrollment periods under paragraphs (1) and (2).

(c)Special rules for network plans

(1)In general

In the case of a health insurance issuer that offers health insurance coverage in the group and individual market through a network plan, the issuer may—

(A)limit the employers that may apply for such coverage to those with eligible individuals who live, work, or reside in the service area for such network plan; and

(B)within the service area of such plan, deny such coverage to such employers and individuals if the issuer has demonstrated, if required, to the applicable State authority that—

(i)it will not have the capacity to deliver services adequately to enrollees of any additional groups or any additional individuals because of its obligations to existing group contract holders and enrollees, and

(ii)it is applying this paragraph uniformly to all employers and individuals without regard to the claims experience of those individuals, employers and their employees (and their dependents) or any health status-related factor relating to such individuals 1 employees and dependents.

(2)180-day suspension upon denial of coverage

An issuer, upon denying health insurance coverage in any service area in accordance with paragraph (1)(B), may not offer coverage in the group or individual market within such service area for a period of 180 days after the date such coverage is denied.

(d)Application of financial capacity limits

(1)In general

A health insurance issuer may deny health insurance coverage in the group or individual market if the issuer has demonstrated, if required, to the applicable State authority that—

(A)it does not have the financial reserves necessary to underwrite additional coverage; and

(B)it is applying this paragraph uniformly to all employers and individuals in the group or individual market in the State consistent with applicable State law and without regard to the claims experience of those individuals, employers and their employees (and their dependents) or any health status-related factor relating to such individuals, employees and dependents.

(2)180-day suspension upon denial of coverage

A health insurance issuer upon denying health insurance coverage in connection with group health plans in accordance with paragraph (1) in a State may not offer coverage in connection with group health plans in the group or individual market in the State for a period of 180 days after the date such coverage is denied or until the issuer has demonstrated to the applicable State authority, if required under applicable State law, that the issuer has sufficient financial reserves to underwrite additional coverage, whichever is later. An applicable State authority may provide for the application of this subsection on a service-area-specific basis.

Notes & Related Subsidiaries

Editorial Notes

Codification The text of section 300gg–11 of this title, which was amended and transferred to subsecs. (c) and (d) of this section by Pub. L. 111–148, § 1563(c)(8), formerly § 1562(c)(8), as renumbered by Pub. L. 111–148, § 10107(b)(1), was based on act July 1, 1944, ch. 373, title XXVII, § 2731, formerly § 2711, as added Pub. L. 104–191, title I, § 102(a), Aug. 21, 1996, 110 Stat. 1962; renumbered § 2731, Pub. L. 111–148, title I, § 1001(3), Mar. 23, 2010, 124 Stat. 130.

Prior Provisions

A prior section 300gg–1, act

July 1, 1944, ch. 373, title XXVII, § 2702, as added Pub. L. 104–191, title I, § 102(a), Aug. 21, 1996, 110 Stat. 1961; Pub. L. 110–233, title I, § 102(a)(1)–(3),

May 21, 2008, 122 Stat. 888, 890, which related to prohibition on discrimination against individual participants and beneficiaries based on health status, was amended by Pub. L. 111–148, title I, § 1201(3), Mar. 23, 2010, 124 Stat. 154, effective for plan years beginning on or after Jan. 1, 2014, and was transferred to subsecs. (b) to (f) of section 300gg–4 of this title. Another prior section 2702 of act

July 1, 1944, was successively renumbered by subsequent acts and transferred, see section 238a of this title.

Amendments

2010—Pub. L. 111–148, § 1563(c)(8), formerly § 1562(c)(8), as renumbered by Pub. L. 111–148, § 10107(b)(1), transferred section 300gg–11 of this title to the end of this section after amending it by striking out the section catchline “Guaranteed availability of coverage for employers in group market”, by striking out subsec. (a) which related to issuance of coverage in small group market, subsec. (b) which related to assurance of access in large group market, subsec. (e) which related to exception to requirement for failure to meet certain minimum participation or contribution rules, and subsec. (f) which related to exception for coverage offered only to bona fide association members, by amending subsec. (c) by substituting “group and individual” for “small group” in introductory provisions of par. (1), inserting “and individuals” after “employers” in introductory provisions of par. (1)(B), inserting “or any additional individuals” after “additional groups” in par. (1)(B)(i), substituting “and individuals without regard to the claims experience of those individuals, employers and their employees (and their dependents) or any health status-related factor relating to such individuals” for “without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such” in par. (1)(B)(ii), and substituting “group or individual” for “small group” in par. (2), and by amending subsec. (d) by substituting “group or individual” for “small group” wherever appearing and substituting “all employers and individuals” for “all employers”, “those individuals, employers” for “those employers”, and “such individuals, employees” for “such employees” in par. (1)(B).

Statutory Notes and Related Subsidiaries

Effective Date

Section effective for plan years beginning on or after Jan. 1, 2014, see section 1255 of Pub. L. 111–148, set out as a note under section 300gg of this title.

§300gg–1 Guaranteed Availability of Coverage