Current through Register Vol. XLI, No. 38, September 20, 2024
3.1. Except as
provided in subsection 3.2, an insurer that provides accident and sickness insurance
coverage in the individual market may not decline to offer coverage or deny
enrollment under any policy form it actively markets in the individual market to any
eligible individual who applies for coverage within sixty-three days after
termination of the individual's prior creditable coverage. An insurer is deemed to
meet this requirement if, upon the request of an eligible individual, it promptly:
a. Provides information about all available
coverage options;
b. Enrolls the
individual in any coverage option the individual selects; and
c. Does not impose any preexisting condition
exclusion on the individual.
3.2. An insurer may elect to limit the coverage
required under subsection 3.1 if it offers eligible individuals at least two policy
forms that meet the following requirements:
a.
Each policy form must be designed for, made generally available to, and actively
marketed to, and enroll both eligible and other individuals; and
b. The policy forms must be either the insurer's
two most popular policy forms (as described in paragraph 1 of this subdivision and
as set forth in W. Va. Code '33-15-2b)
or representative samples of individual accident and sickness insurance (as
described in paragraph 2 of this subdivision and as set forth in W. Va. Code
'33-15-2b)
offered by the insurer in this State.
1. The two
most popular forms means the policy forms with the largest, and the second largest,
premium volume for the last reporting year, for policies offered in the State.
Premium volume means earned premiums for the last reporting year. The last reporting
year is the period from October 1 through September 30 of the preceding year. Blocks
of business closed under applicable State law are not included in calculating
premium volume.
2. The two
representative policy forms must meet the following requirements:
A. Include a lower-level coverage policy form
under which the actuarial value of benefits under the coverage is at least 85
percent but not greater than 100 percent of the weighted average; and
B. Include a higher level coverage policy form
under which the actuarial value of the benefits under the coverage is at least 15
percent greater than the actuarial value of the lower-level coverage policy form
offered by an insurer in the State and at least 100 percent, but not greater than
120 percent of the weighted average;
C.
Include benefits substantially similar to other individual accident and sickness
insurance coverage offered by the insurer in the state;
D. Provide for risk adjustment, risk spreading, or
a risk spreading mechanism, or otherwise provide some financial subsidization for
eligible individuals; and
E. Meet all
applicable State requirements.
3.3. All elections by insurers as provided for in
subsection 3.2 of this rule must be applied uniformly to all eligible individuals in
the State and must be effective for all policies offered during a period of at least
two years.
3.4. Insurers making
elections must do so on a form prescribed by the Commissioner within the following
time frames:
a. For policy forms already being
marketed as of July 1, 1997--no later than September 1, 1997.
b. For other policy forms--90 days before the
beginning of the calendar year in which the insurer wants to market the policy
form.
