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United States Code (Last Updated: May 24, 2014) |
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Title 42. THE PUBLIC HEALTH AND WELFARE |
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Chapter 6A. PUBLIC HEALTH SERVICE |
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SubChapter XXV. REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE |
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Part A. Individual and Group Market Reforms |
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SubPart 1. general reform |
§ 300gg–2. Guaranteed renewability of coverage
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(a) In general Except as provided in this section, if a health insurance issuer offers health insurance coverage in the individual or group market, the issuer must renew or continue in force such coverage at the option of the plan sponsor or the individual, as applicable.
(b) General exceptions A health insurance issuer may nonrenew or discontinue health insurance coverage offered in connection with a health insurance coverage offered in the group or individual market based only on one or more of the following: (1) Nonpayment of premiums The plan sponsor, or individual, as applicable, has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the issuer has not received timely premium payments.
(2) Fraud The plan sponsor, or individual, as applicable, has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.
(3) Violation of participation or contribution rates In the case of a group health plan, the plan sponsor has failed to comply with a material plan provision relating to employer contribution or group participation rules, pursuant to applicable State law.
(4) Termination of coverage The issuer is ceasing to offer coverage in such market in accordance with subsection (c) of this section and applicable State law.
(5) Movement outside service area In the case of a health insurance issuer that offers health insurance coverage in the market through a network plan, there is no longer any enrollee in connection with such plan who lives, resides, or works in the service area of the issuer (or in the area for which the issuer is authorized to do business) and, in the case of the small group market, the issuer would deny enrollment with respect to such plan under section 2711(c)(1)(A). (and participants and beneficiaries covered under such coverage) of such discontinuation at least 180 days prior to the date of the discontinuation of such coverage; and
(ii) all health insurance issued or delivered for issuance in the State in such market (or markets) are discontinued and coverage under such health insurance coverage in such market (or markets) is not renewed. (B) Prohibition on market reentry In the case of a discontinuation under subparagraph (A) in a market, the issuer may not provide for the issuance of any health insurance coverage in the market and State involved during the 5-year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.
(d) Exception for uniform modification of coverage At the time of coverage renewal, a health insurance issuer may modify the health insurance coverage for a product offered to a group health plan— (1) in the large group market; or (2) in the small group market if, for coverage that is available in such market other than only through one or more bona fide associations, such modification is consistent with State law and effective on a uniform basis among group health plans with that product. (e) Application to coverage offered only through associations In applying this section in the case of health insurance coverage that is made available by a health insurance issuer in the small or large group market to employers only through one or more associations, a reference to “plan sponsor” is deemed, with respect to coverage provided to an employer member of the association, to include a reference to such employer.
References In Text
Section 2711, referred to in subsec. (b)(5), is a reference to section 2711 of act
Codification
The text of section 300gg–12 of this title, which was amended and transferred to subsecs. (b) to (e) of this section by Pub. L. 111–148, § 1563(c)(9), formerly § 1562(c)(9), as renumbered by Pub. L. 111–148, § 10107(b)(1), was based on act July 1, 1944, ch. 373, title XXVII, § 2732, formerly § 2712, as added Pub. L. 104–191, title I, § 102(a),
Prior Provisions
A prior section 2703 of act
Amendments
2010—Pub. L. 111–148, § 1563(c)(9), formerly § 1562(c)(9), as renumbered by Pub. L. 111–148, § 10107(b)(1), transferred section 300gg–12 of this title to the end of this section after amending it by striking out the section catchline “Guaranteed renewability of coverage for employers in group market”, by striking subsec. (a) which required a health insurance issuer offering coverage in connection with a group health plan to renew such coverage at the option of the plan sponsor, by amending subsec. (b) by substituting “health insurance coverage offered in the group or individual market” for “group health plan in the small or large group market” in introductory provisions, inserting “, or individual, as applicable,” after “plan sponsor” in pars. (1) and (2), adding par. (3), and striking out former par. (3) which related to violation of participation or contribution rules, and by amending subsec. (c) by substituting “group or individual health insurance coverage” for “group health insurance coverage offered in the small or large group market” in introductory provisions of par. (1), inserting “or individual, as applicable,” after “plan sponsor” in par. (1)(A) and (B), inserting “or individual health insurance coverage” in par. (1)(B), inserting “or individuals, as applicable,” after “those sponsors” in par. (1)(C), substituting “individual or group market, or all markets,” for “small group market or the large group market, or both markets,” in introductory provisions of par. (2)(A), and inserting “or individual, as applicable,” after “plan sponsor” in par. (2)(A)(i). Amendment inserting “or individual health insurance coverage” in subsec. (c)(1)(B) was executed by making the insertion after “group health plan” as the probable intent of Congress, notwithstanding that the directory language did not specify where in subsec. (c)(1)(B) to make the insertion.
Effective Date
Section effective for plan years beginning on or after