§ 27-18.5-3. Guaranteed availability.
(a) Subject to subsections (b) — (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.
(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.