Merged Individual and Small Group Market

Section 81: Merged Non-Group and Small Group Insurance Markets

Allows individuals to purchase coverage through the small group insurance market, and provides that the small group insurance law provisions apply to all small business and individual plans issued by an insurance carrier, by the Connector, or through an intermediary.

Section 82: Permitted Premium Rate Factors

Sets the factors used to set premiums for the merged individual and small group market. This section establishes a maximum rate band range from .66 to 1.32 for the following factors: age, industry rate, participation-rate rate, wellness program rate, and tobacco use rate. Additionally, carriers can apply only the following factors outside the rating band in establishing premiums: benefit level, geographic region, adjustment factor for an eligible individual and a small group, and group size. Additionally, requirements are laid out for which carriers with 5,000 or more members will be required to file a plan annually with the Connector to be considered for the "Connector Seal of Approval."

Section 83: Private Insurance Requirements

Requires insurance carriers to make available to individuals and small groups information for all plans and prices of plans offered to any other individuals and small groups. • Modifies the current requirement of carriers to make health benefit plans available in the following ways: Requires carriers to offer coverage effective within 30 days after application to any eligible individuals if they request coverage within 63 days of any prior creditable coverage. If the 63 day period has lapsed, carriers must offer coverage effective on the first day of the month following enrollment to eligible individuals who apply during the mandatory biannual open enrollment periods. • For a Trade Act/Health Coverage Tax Credit Eligible Individual, carriers may impose a 6 month exclusion of coverage for pre-existing conditions if the individual had less than 3 months of continuous coverage before becoming eligible for the tax credit or had a break in coverage for more than 62 days before applying for the plan. However, plans offered to individuals without creditable coverage for 18 months prior to application may not be subjected to a waiting period. • A carrier can deny enrollment in any plan if the carrier files with the Commissioner proof of intent to stop selling that plan. • Carriers can require individuals or groups of 1-5 to enroll in plans via the Connector or an intermediary.

Sections 85 & 86: Division of Insurance Rate Review

Provides that the Commissioner of the Division of Insurance may approve, according to established criteria, health insurance policies for individuals or small businesses that cover more restricted networks that differ from the overall carrier's network. The Commissioner may also disapprove any proposed rate changes if the Commissioner disapproves proposed rate increases to a small group plan, an insurance carrier must notify all members of the plan that the proposed increase has been disapproved and is subject to a public hearing. The carrier may not implement the proposed rates until the Commissioner has approved the rates.