SECTION 1 (TITLE):
This act shall be known as the Protect Coverage for Preexisting Conditions Act.
SECTION 2 (PURPOSE):
This bill establishes protections for those with preexisting conditions who seek to obtain health insurance coverage.
SECTION 3 (PROVISIONS):
(a) A carrier offering an individual, group or small employer health benefit plan in this state shall not impose any preexisting condition exclusion with respect to coverage under the plan.
(b) A preexisting condition exclusion means a limitation or exclusion of benefits (including a denial of coverage) based on the fact that the condition was present before the effective date of coverage (or if coverage is denied, the date of the denial) under a group health plan or group or individual health insurance coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that day.
(c) Each carrier 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 who is eligible to apply.
(d) With respect to the premium rates charged by a carrier offering an individual or small employer health benefit plan, the carrier shall develop its premium rates based on, and vary the premium rates with respect to the particular plan or coverage only by the following case characteristics:
- (i) whether the plan or coverage covers an individual or family;
- (ii) geographic rating area, established in accordance with federal law;
- (iii) age, except that the rate must not vary by more than three to one for adults; and
- (iv) tobacco use, except that the rate must not vary by more than one and one-fifteenth to one.
- (v) With respect to family coverage under an individual or small employer health benefit plan, the carrier shall apply the rating variations permitted under this subsection based on the portion of the premium that is attributable to each family member covered under the plan in accordance with rules of the commissioner.
(e) The carrier shall not adjust the premium charged with respect to any particular individual or small employer health benefit plan more frequently than annually; except that the carrier may change the premium rates to reflect:
- (i) with respect to a small employer health benefit plan, changes to the enrollment of the small employer;
- (ii) changes to the family composition of the policyholder or employee;
- (iii) with respect to an individual health benefit plan, changes in geographic rating area of the policyholder or changes in tobacco use, as provided in subsection (d);
- (iv) changes to the health benefit plan requested by the policyholder or small employer; or
- (v) other changes required by federal law or regulations or otherwise expressly permitted by state law or regulation.
(f) The COMMISSIONER may adopt rules to implement and administer this subsection and to assure that rating practices used by carriers are consistent with the purposes of this article.