(a)Guaranteed availability of coverage in the individual market. —Subject to subsections (b)-
(d)of this section, a carrier that offers health insurance coverage in the individual market in this State must offer to any individual in this State all products that are approved for sale in the individual market, and must accept any individual that applies for any of those products.
(b)Enrollment periods. —A carrier may restrict enrollment in health insurance coverage to open or special enrollment periods.
(1)Open enrollment periods in the individual market. —
A carrier in the individual market must permit an individual to purchase health insurance coverage during an annual open enrollment period. For benefit years beginning on or after January 1, 2018, the annual open enrollment period begi
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(a)Guaranteed availability of coverage in the individual market. —Subject to subsections (b)-(d) of this section, a carrier that offers health insurance coverage in the individual market in this State must offer to any individual in this State all products that are approved for sale in the individual market, and must accept any individual that applies for any of those products.
(b)Enrollment periods. —A carrier may restrict enrollment in health insurance coverage to open or special enrollment periods.
(1)Open enrollment periods in the individual market. —
A carrier in the individual market must permit an individual to purchase health insurance coverage during an annual open enrollment period. For benefit years beginning on or after January 1, 2018, the annual open enrollment period begins on November 1 and extends through December 15 of the calendar year preceding the benefit year. A carrier must ensure that coverage is effective January 1 for enrollments received by the carrier on or before December 15 of the calendar year preceding the benefit year.
(2)Special enrollment periods. —
A carrier in the individual market shall establish special enrollment periods for qualifying events as defined under § 603 of the Employee Retirement Income Security Act of 1974, as amended [29 USC § 1163]. Enrollees must be provided 30 calendar days after the date of the qualifying event to elect coverage, with such coverage becoming effective consistent with the dates described in 45 C.F.R. § 155.420(b), as in effect on January 1, 2025. These special enrollment periods are in addition to any other special enrollment periods that are required under federal and state law.
(c)Special rules for network plans. —(1) In the case of a carrier that offers health insurance coverage in the individual market through a network plan, the carrier may do the following:
a. Limit the individuals who may apply for the coverage in the individual market to those who live or reside in the service area for the network plan.
b. Within the service area of the plan, deny coverage to individuals if the carrier has demonstrated to the Commissioner the following:
1. It will not have the capacity to deliver services adequately to enrollees of any additional individuals because of its obligations to existing contract holders and enrollees.
2. It is applying paragraph (c)(1) of this section uniformly to all individuals without regard to the claims experience of those individuals (and their dependents) or any health-status related factor relating to such individuals and dependents.
(2) A carrier that denies health insurance coverage to an individual in any service area, in accordance with paragraph (c)(1)b. of this section, may not offer coverage in the individual market within the service area to any individual for a period of 180 calendar days after the date the coverage is denied. This paragraph (c)(2) does not limit the carrier’s ability to renew coverage already in force or relieve the carrier of the responsibility to renew that coverage.
(3) Coverage offered within a service area after the 180-day period specified in paragraph (c)(2) of this section is subject to the requirements of this section.
(d)Application of financial capacity limits. —(1) A carrier may deny health insurance coverage in the individual market if the carrier has demonstrated to the Commissioner the following:
a. It does not have the financial reserves necessary to underwrite additional coverage.
b. It is applying this paragraph (d)(1) uniformly to all individuals in the individual market in this State consistent with applicable state law and without regard to the claims experience of those individuals (and their dependents) or any health status-related factor relating to such individuals and dependents.
(2) A carrier that denies health insurance coverage to any individual in this State under paragraph (d)(1) of this section may not offer coverage in the individual market in this State before the later of either of the following dates:
a. The one hundred and eighty-first day after the date the carrier denies coverage;
b. The date the carrier demonstrates to the Commissioner that the carrier has sufficient reserves to underwrite additional coverage.
(3) Paragraph (d)(2) of this section does not limit the carrier’s ability to renew coverage already in force or relieve the carrier of the responsibility to renew that coverage.
(4) Coverage offered after the 180-day period specified in paragraph (d)(2) of this section is subject to the requirements of this section.
(5) The Commissioner may provide for the application of this subsection (d) on service-area-specific basis.
(e)Marketing. —A carrier and its officials, employees, agents and representatives must comply with any applicable state laws and regulations regarding marketing by carriers and cannot employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs in health insurance coverage.
(f)Grandfathered health plans. —This section does not apply to grandfathered health plans. For purposes of this section, “grandfathered health plans” means plans provided by a health insurer in which an individual was enrolled on March 23, 2010, for as long as it maintains that status in accordance with federal regulations.