Current through Register 1531, September 27, 2024
(1) As a condition
of continued offer of small group insured Health Benefit Plans, a Carrier that,
as of the close of the preceding calendar year, has a combined total of at
least 5,000 Eligible Individuals, Eligible Employees and Eligible Dependents
who are enrolled in Health Benefit Plans sold, issued, delivered, made
effective or renewed shall be required to annually file a Health Benefit Plan
and accompanying rates according to the Health Benefit Plan specifications
developed by a certified Group Purchasing Cooperative for the Group Purchasing
Cooperative's consideration, if said certified Group Purchasing Cooperative
requests such Health Benefit Plan proposals for its next plan year.
(2) Acceptable Health Benefit Plan features
shall include, but not be limited to, the following:
(a) All Health Benefit Plans offered by a
Carrier through each certified Group Purchasing Cooperative are to include
Mandated Benefits and comply with all additional relevant statutory and
regulatory requirements for insured Health Benefit Plans.
(b) For Eligible Small Businesses or
Qualified Associations of five or fewer Eligible Employees or Eligible
Association Members, a Carrier may require a Participation Rate not to exceed
100%. For Eligible Small Businesses or Qualified Associations of six or more
Eligible Employees or Eligible Association Members, a Carrier may require a
Participation Rate not to exceed 75%.
(c) Pre-existing condition limitations and
Waiting Periods are to be applied by a Carrier within Health Benefit Plans
offered through each certified Group Purchasing Cooperative in the same manner
that they are applied to individuals and small employer groups enrolling in
coverage outside the certified Group Purchasing Cooperative.
(d) Continuation of coverage provisions are
to be applied by a Carrier within Health Benefit Plans offered through each
certified Group Purchasing Cooperative in the same manner that they are applied
to individuals and small employer groups enrolling in coverage outside the
certified Group Purchasing Cooperative.
(e) Managed care practices, including
utilization review, quality assurance, credentialing of health plan providers,
and dissemination of required consumer materials are to be applied by a Carrier
within a Health Benefit Plan offered through each certified Group Purchasing
Cooperative in the same manner that they are applied to individuals and small
employer groups enrolling in coverage outside the certified Group Purchasing
Cooperative.
(3)
Requirements of Premium Rates Offered by Carriers are as follows:
(a) For all rates offered by a Carrier
through each certified Group Purchasing Cooperative, the Carrier shall apply
rating rules, including rating bands, rating factors and the value of rating
factors in the same manner as the Carrier applies those rules to insured Health
Benefit Plans offered to individuals and small employer groups outside the
certified Group Purchasing Cooperative.
(b) Carriers may submit a rate filing with
respect to any cooperative adjustment factor, benefit adjustment factor, or
limited deviation, and Carriers may apply for the Commissioner's approval to
make limited deviations from required application of rating factors.
(c) The rates offered by a Carrier through
each certified Group Purchasing Cooperative shall be based on those group base
premium rates that apply to individuals and small employer groups enrolling
outside the Group Purchasing Cooperative but may differ based as follows:
1. A benefit rate adjustment factor that is
applied to the certified Group Purchasing Cooperative product if its Covered
Benefits are different than those outside the certified Group Purchasing
Cooperative;
2. A cooperative
adjustment factor that reflects the relative difference in the projected
experience of the members projected to be enrolled in Health Benefit Plans
through the certified Group Purchasing Cooperative relative to the projected
experience of the members projected to be enrolled in Health Benefit Plans
outside the certified Group Purchasing Cooperative; and
3. Any other rate adjustment factor that has
received written prior approval from the Commissioner.