AN
ACT Relating to mandatory offering of basic health plan benefits; amending RCW
48.20.028, 48.21.045, 48.44.022, 48.44.023, 48.46.064, and 48.46.066; and
creating a new section.
BE IT ENACTED BY THE
LEGISLATURE OF THE STATE OF WASHINGTON:
Sec.
1. RCW
48.20.028 and 1995 c 265 s 13 are each amended to read as follows:
(1)(a)
An insurer offering any health benefit plan to any individual shall offer and
actively market to all individuals a health benefit plan providing benefits
identical to the schedule of covered health services that are required to be
delivered to an individual enrolled in the basic health plan. Nothing in this
subsection shall preclude an insurer from offering, or an individual from
purchasing, other health benefit plans that may have more or less comprehensive
benefits than the basic health plan, provided such plans are in accordance with
this chapter. An insurer offering a health benefit plan that does not include
benefits provided in the basic health plan shall clearly disclose these
differences to the individual in a brochure approved by the commissioner.
(b)
A health benefit plan shall provide coverage for hospital expenses and services
rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not
subject to the requirements of RCW 48.20.390, 48.20.393, 48.20.395, 48.20.397,
48.20.410, 48.20.411, 48.20.412, 48.20.416, and 48.20.420 if the health benefit
plan is the mandatory offering under (a) of this subsection that provides
benefits identical to the basic health plan, to the extent these requirements
differ from the basic health plan.
(2)
Premiums for health benefit plans for individuals shall be calculated using the
adjusted community rating method that spreads financial risk across the
carrier's entire individual product population. All such rates shall conform
to the following:
(a)
The insurer shall develop its rates based on an adjusted community rate and may
only vary the adjusted community rate for:
(i)
Geographic area;
(ii)
Family size;
(iii)
Age; and
(iv)
Wellness activities.
(b)
The adjustment for age in (a)(iii) of this subsection may not use age brackets
smaller than five-year increments which shall begin with age twenty and end
with age sixty-five. Individuals under the age of twenty shall be treated as
those age twenty.
(c)
The insurer shall be permitted to develop separate rates for individuals age
sixty-five or older for coverage for which medicare is the primary payer and
coverage for which medicare is not the primary payer. Both rates shall be
subject to the requirements of this subsection.
(d)
The permitted rates for any age group shall be no more than four hundred
twenty-five percent of the lowest rate for all age groups on January 1, 1996,
four hundred percent on January 1, 1997, and three hundred seventy-five percent
on January 1, 2000, and thereafter.
(e)
A discount for wellness activities shall be permitted to reflect actuarially
justified differences in utilization or cost attributed to such programs not to
exceed twenty percent.
(f)
The rate charged for a health benefit plan offered under this section may not
be adjusted more frequently than annually except that the premium may be
changed to reflect:
(i)
Changes to the family composition;
(ii)
Changes to the health benefit plan requested by the individual; or
(iii)
Changes in government requirements affecting the health benefit plan.
(g)
The frequency of filing of rate adjustments for new and renewing individuals is
limited to once every six months.
(((g)))
(h) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a provision,
provided that the restrictions of benefits to network providers result in
substantial differences in claims costs. This subsection does not restrict or
enhance the portability of benefits as provided in RCW 48.43.015.
(3)
Adjusted community rates established under this section shall pool the medical
experience of all individuals purchasing coverage, and shall not be required to
be pooled with the medical experience of health benefit plans offered to small
employers under RCW 48.21.045.
(4)
As used in this section, "health benefit plan," "basic health
plan," "adjusted community rate," and "wellness
activities" mean the same as defined in RCW 48.43.005.
Sec.
2. RCW
48.21.045 and 1995 c 265 s 14 are each amended to read as follows:
(1)(a)
An insurer offering any health benefit plan to a small employer shall offer and
actively market to the small employer a health benefit plan providing benefits
identical to the schedule of covered health services that are required to be
delivered to an individual enrolled in the basic health plan. Nothing in this
subsection shall preclude an insurer from offering, or a small employer from
purchasing, other health benefit plans that may have more or less comprehensive
benefits than the basic health plan, provided such plans are in accordance with
this chapter. An insurer offering a health benefit plan that does not include
benefits in the basic health plan shall clearly disclose these differences to
the small employer in a brochure approved by the commissioner.
(b)
A health benefit plan shall provide coverage for hospital expenses and services
rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not
subject to the requirements of RCW 48.21.130, 48.21.140, 48.21.141, 48.21.142,
48.21.144, 48.21.146, 48.21.160 through 48.21.197, 48.21.200, 48.21.220,
48.21.225, 48.21.230, 48.21.235, 48.21.240, 48.21.244, 48.21.250, 48.21.300,
48.21.310, or 48.21.320 if: (i) The health benefit plan is the mandatory
offering under (a) of this subsection that provides benefits identical to the
basic health plan, to the extent these requirements differ from the basic
health plan; or (ii) the health benefit plan is offered to employers with not
more than twenty-five employees.
(2)
Nothing in this section shall prohibit an insurer from offering, or a purchaser
from seeking, benefits in excess of the basic health plan services. All forms,
policies, and contracts shall be submitted for approval to the commissioner,
and the rates of any plan offered under this section shall be reasonable in
relation to the benefits thereto.
(3)
Premium rates for health benefit plans for small employers as defined in this
section shall be subject to the following provisions:
(a)
The insurer shall develop its rates based on an adjusted community rate and may
only vary the adjusted community rate for:
(i)
Geographic area;
(ii)
Family size;
(iii)
Age; and
(iv)
Wellness activities.
(b)
The adjustment for age in (a)(iii) of this subsection may not use age brackets
smaller than five-year increments, which shall begin with age twenty and end
with age sixty-five. Employees under the age of twenty shall be treated as
those age twenty.
(c)
The insurer shall be permitted to develop separate rates for individuals age
sixty-five or older for coverage for which medicare is the primary payer and
coverage for which medicare is not the primary payer. Both rates shall be
subject to the requirements of this subsection (3).
(d)
The permitted rates for any age group shall be no more than four hundred
twenty-five percent of the lowest rate for all age groups on January 1, 1996,
four hundred percent on January 1, 1997, and three hundred seventy-five percent
on January 1, 2000, and thereafter.
(e)
A discount for wellness activities shall be permitted to reflect actuarially
justified differences in utilization or cost attributed to such programs not to
exceed twenty percent.
(f)
The rate charged for a health benefit plan offered under this section may not
be adjusted more frequently than annually except that the premium may be
changed to reflect:
(i)
Changes to the enrollment of the small employer;
(ii)
Changes to the family composition of the employee;
(iii)
Changes to the health benefit plan requested by the small employer; or
(iv)
Changes in government requirements affecting the health benefit plan.
(g)
The frequency of filing of rate adjustments for new and renewing small
employers is limited to once every six months.
(((g)))
(h) Rating factors shall produce premiums for identical groups that
differ only by the amounts attributable to plan design, with the exception of
discounts for health improvement programs.
(((h)))
(i) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a provision,
provided that the restrictions of benefits to network providers result in
substantial differences in claims costs. This subsection does not restrict or
enhance the portability of benefits as provided in RCW 48.43.015.
(((i)))
(j) Adjusted community rates established under this section shall pool
the medical experience of all small groups purchasing coverage.
(4)
The health benefit plans authorized by this section that are lower than the
required offering shall not supplant or supersede any existing policy for the
benefit of employees in this state. Nothing in this section shall restrict the
right of employees to collectively bargain for insurance providing benefits in
excess of those provided herein.
(5)(a)
Except as provided in this subsection, requirements used by an insurer in
determining whether to provide coverage to a small employer shall be applied
uniformly among all small employers applying for coverage or receiving coverage
from the carrier.
(b)
An insurer shall not require a minimum participation level greater than:
(i)
One hundred percent of eligible employees working for groups with three or less
employees; and
(ii)
Seventy-five percent of eligible employees working for groups with more than
three employees.
(c)
In applying minimum participation requirements with respect to a small
employer, a small employer shall not consider employees or dependents who have
similar existing coverage in determining whether the applicable percentage of
participation is met.
(d)
An insurer may not increase any requirement for minimum employee participation
or modify any requirement for minimum employer contribution applicable to a
small employer at any time after the small employer has been accepted for
coverage.
(6)
An insurer must offer coverage to all eligible employees of a small employer
and their dependents. An insurer may not offer coverage to only certain
individuals or dependents in a small employer group or to only part of the
group. An insurer may not modify a health plan with respect to a small
employer or any eligible employee or dependent, through riders, endorsements or
otherwise, to restrict or exclude coverage or benefits for specific diseases,
medical conditions, or services otherwise covered by the plan.
(7)
As used in this section, "health benefit plan," "small
employer," "basic health plan," "adjusted community
rate," and "wellness activities" mean the same as defined in RCW
48.43.005.
Sec.
3. RCW
48.44.022 and 1995 c 265 s 15 are each amended to read as follows:
(1)(a)
A health care service contractor offering any health benefit plan to any
individual shall offer and actively market to all individuals a health benefit
plan providing benefits identical to the schedule of covered health services
that are required to be delivered to an individual enrolled in the basic health
plan. Nothing in this subsection shall preclude a contractor from offering, or
an individual from purchasing, other health benefit plans that may have more or
less comprehensive benefits than the basic health plan, provided such plans are
in accordance with this chapter. A contractor offering a health benefit plan
that does not include benefits provided in the basic health plan shall clearly
disclose these differences to the individual in a brochure approved by the
commissioner.
(b)
A health benefit plan shall provide coverage for hospital expenses and services
rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not
subject to the requirements of RCW 48.44.225, 48.44.240, 48.44.245, 48.44.290,
48.44.300, 48.44.310, 48.44.320, 48.44.325, 48.44.330, 48.44.335, 48.44.340,
48.44.344, 48.44.360, 48.44.400, 48.44.440, 48.44.450, and 48.44.460 if the
health benefit plan is the mandatory offering under (a) of this subsection that
provides benefits identical to the basic health plan, to the extent these
requirements differ from the basic health plan.
(2)
Premium rates for health benefit plans for individuals shall be subject to the
following provisions:
(a)
The health care service contractor shall develop its rates based on an adjusted
community rate and may only vary the adjusted community rate for:
(i)
Geographic area;
(ii)
Family size;
(iii)
Age; and
(iv)
Wellness activities.
(b)
The adjustment for age in (a)(iii) of this subsection may not use age brackets
smaller than five-year increments which shall begin with age twenty and end
with age sixty-five. Individuals under the age of twenty shall be treated as
those age twenty.
(c)
The health care service contractor shall be permitted to develop separate rates
for individuals age sixty-five or older for coverage for which medicare is the
primary payer and coverage for which medicare is not the primary payer. Both
rates shall be subject to the requirements of this subsection.
(d)
The permitted rates for any age group shall be no more than four hundred
twenty-five percent of the lowest rate for all age groups on January 1, 1996,
four hundred percent on January 1, 1997, and three hundred seventy-five percent
on January 1, 2000, and thereafter.
(e)
A discount for wellness activities shall be permitted to reflect actuarially
justified differences in utilization or cost attributed to such programs not to
exceed twenty percent.
(f)
The rate charged for a health benefit plan offered under this section may not
be adjusted more frequently than annually except that the premium may be
changed to reflect:
(i)
Changes to the family composition;
(ii)
Changes to the health benefit plan requested by the individual; or
(iii)
Changes in government requirements affecting the health benefit plan.
(g)
The frequency of filing of rate adjustments for new and renewing individuals is
limited to once every six months.
(((g)))
(h) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a provision,
provided that the restrictions of benefits to network providers result in
substantial differences in claims costs. This subsection does not restrict or
enhance the portability of benefits as provided in RCW 48.43.015.
(3)
Adjusted community rates established under this section shall pool the medical
experience of all individuals purchasing coverage, and shall not be required to
be pooled with the medical experience of health benefit plans offered to small
employers under RCW 48.44.023.
(4)
As used in this section and RCW 48.44.023 "health benefit plan,"
"small employer," "basic health plan," "adjusted
community rates," and "wellness activities" mean the same as
defined in RCW 48.43.005.
Sec.
4. RCW
48.44.023 and 1995 c 265 s 16 are each amended to read as follows:
(1)(a)
A health care services contractor offering any health benefit plan to a small
employer shall offer and actively market to the small employer a health benefit
plan providing benefits identical to the schedule of covered health services
that are required to be delivered to an individual enrolled in the basic health
plan. Nothing in this subsection shall preclude a contractor from offering, or
a small employer from purchasing, other health benefit plans that may have more
or less comprehensive benefits than the basic health plan, provided such plans
are in accordance with this chapter. A contractor offering a health benefit
plan that does not include benefits in the basic health plan shall clearly
disclose these differences to the small employer in a brochure approved by the
commissioner.
(b)
A health benefit plan shall provide coverage for hospital expenses and services
rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not
subject to the requirements of RCW 48.44.225, 48.44.240, 48.44.245, 48.44.290,
48.44.300, 48.44.310, 48.44.320, 48.44.325, 48.44.330, 48.44.335, 48.44.340,
48.44.344, 48.44.360, 48.44.400, 48.44.440, 48.44.450, and 48.44.460 if: (i)
The health benefit plan is the mandatory offering under (a) of this subsection
that provides benefits identical to the basic health plan, to the extent these
requirements differ from the basic health plan; or (ii) the health benefit plan
is offered to employers with not more than twenty-five employees.
(2)
Nothing in this section shall prohibit a health care service contractor from
offering, or a purchaser from seeking, benefits in excess of the basic health
plan services. All forms, policies, and contracts shall be submitted for
approval to the commissioner, and the rates of any plan offered under this
section shall be reasonable in relation to the benefits thereto.
(3)
Premium rates for health benefit plans for small employers as defined in this
section shall be subject to the following provisions:
(a)
The contractor shall develop its rates based on an adjusted community rate and
may only vary the adjusted community rate for:
(i)
Geographic area;
(ii)
Family size;
(iii)
Age; and
(iv)
Wellness activities.
(b)
The adjustment for age in (a)(iii) of this subsection may not use age brackets
smaller than five-year increments, which shall begin with age twenty and end
with age sixty-five. Employees under the age of twenty shall be treated as
those age twenty.
(c)
The contractor shall be permitted to develop separate rates for individuals age
sixty-five or older for coverage for which medicare is the primary payer and
coverage for which medicare is not the primary payer. Both rates shall be
subject to the requirements of this subsection (3).
(d)
The permitted rates for any age group shall be no more than four hundred
twenty-five percent of the lowest rate for all age groups on January 1, 1996,
four hundred percent on January 1, 1997, and three hundred seventy-five percent
on January 1, 2000, and thereafter.
(e)
A discount for wellness activities shall be permitted to reflect actuarially
justified differences in utilization or cost attributed to such programs not to
exceed twenty percent.
(f)
The rate charged for a health benefit plan offered under this section may not
be adjusted more frequently than annually except that the premium may be
changed to reflect:
(i)
Changes to the enrollment of the small employer;
(ii)
Changes to the family composition of the employee;
(iii)
Changes to the health benefit plan requested by the small employer; or
(iv)
Changes in government requirements affecting the health benefit plan.
(g)
The frequency of filing of rate adjustments for new and renewing small
employers is limited to once every six months.
(((g)))
(h) Rating factors shall produce premiums for identical groups that
differ only by the amounts attributable to plan design, with the exception of
discounts for health improvement programs.
(((h)))
(i) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a provision,
provided that the restrictions of benefits to network providers result in
substantial differences in claims costs. This subsection does not restrict or
enhance the portability of benefits as provided in RCW 48.43.015.
(((i)))
(j) Adjusted community rates established under this section shall pool
the medical experience of all groups purchasing coverage.
(4)
The health benefit plans authorized by this section that are lower than the
required offering shall not supplant or supersede any existing policy for the
benefit of employees in this state. Nothing in this section shall restrict the
right of employees to collectively bargain for insurance providing benefits in
excess of those provided herein.
(5)(a)
Except as provided in this subsection, requirements used by a contractor in
determining whether to provide coverage to a small employer shall be applied
uniformly among all small employers applying for coverage or receiving coverage
from the carrier.
(b)
A contractor shall not require a minimum participation level greater than:
(i)
One hundred percent of eligible employees working for groups with three or less
employees; and
(ii)
Seventy-five percent of eligible employees working for groups with more than
three employees.
(c)
In applying minimum participation requirements with respect to a small employer,
a small employer shall not consider employees or dependents who have similar
existing coverage in determining whether the applicable percentage of
participation is met.
(d)
A contractor may not increase any requirement for minimum employee participation
or modify any requirement for minimum employer contribution applicable to a
small employer at any time after the small employer has been accepted for
coverage.
(6)
A contractor must offer coverage to all eligible employees of a small employer
and their dependents. A contractor may not offer coverage to only certain
individuals or dependents in a small employer group or to only part of the
group. A contractor may not modify a health plan with respect to a small
employer or any eligible employee or dependent, through riders, endorsements or
otherwise, to restrict or exclude coverage or benefits for specific diseases,
medical conditions, or services otherwise covered by the plan.
Sec.
5. RCW
48.46.064 and 1995 c 265 s 17 are each amended to read as follows:
(1)(a)
A health maintenance organization offering any health benefit plan to any
individual shall offer and actively market to all individuals a health benefit
plan providing benefits identical to the schedule of covered health services
that are required to be delivered to an individual enrolled in the basic health
plan. Nothing in this subsection shall preclude a health maintenance
organization from offering, or an individual from purchasing, other health
benefit plans that may have more or less comprehensive benefits than the basic
health plan, provided such plans are in accordance with this chapter. A health
maintenance organization offering a health benefit plan that does not include
benefits provided in the basic health plan shall clearly disclose these
differences to the individual in a brochure approved by the commissioner.
(b)
A health benefit plan shall provide coverage for hospital expenses and services
rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not
subject to the requirements of RCW 48.46.275, ((48.26.280 [48.46.280])) 48.46.280,
48.46.285, 48.46.290, 48.46.350, 48.46.355, 48.46.375, 48.46.440, 48.46.480,
48.46.510, 48.46.520, and 48.46.530 if the health benefit plan is the mandatory
offering under (a) of this subsection that provides benefits identical to the
basic health plan, to the extent these requirements differ from the basic
health plan.
(2)
Premium rates for health benefit plans for individuals shall be subject to the
following provisions:
(a)
The health maintenance organization shall develop its rates based on an
adjusted community rate and may only vary the adjusted community rate for:
(i)
Geographic area;
(ii)
Family size;
(iii)
Age; and
(iv)
Wellness activities.
(b)
The adjustment for age in (a)(iii) of this subsection may not use age brackets
smaller than five-year increments which shall begin with age twenty and end
with age sixty-five. Individuals under the age of twenty shall be treated as
those age twenty.
(c)
The health maintenance organization shall be permitted to develop separate
rates for individuals age sixty-five or older for coverage for which medicare
is the primary payer and coverage for which medicare is not the primary payer.
Both rates shall be subject to the requirements of this subsection.
(d)
The permitted rates for any age group shall be no more than four hundred
twenty-five percent of the lowest rate for all age groups on January 1, 1996,
four hundred percent on January 1, 1997, and three hundred seventy-five percent
on January 1, 2000, and thereafter.
(e)
A discount for wellness activities shall be permitted to reflect actuarially
justified differences in utilization or cost attributed to such programs not to
exceed twenty percent.
(f)
The rate charged for a health benefit plan offered under this section may not
be adjusted more frequently than annually except that the premium may be
changed to reflect:
(i)
Changes to the family composition;
(ii)
Changes to the health benefit plan requested by the individual; or
(iii)
Changes in government requirements affecting the health benefit plan.
(g)
The frequency of filing of rate adjustments for new and renewing individuals is
limited to once every six months.
(((g)))
(h) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a provision,
provided that the restrictions of benefits to network providers result in
substantial differences in claims costs. This subsection does not restrict or
enhance the portability of benefits as provided in RCW 48.43.015.
(3)
Adjusted community rates established under this section shall pool the medical
experience of all individuals purchasing coverage, and shall not be required to
be pooled with the medical experience of health benefit plans offered to small
employers under RCW 48.46.066.
(4)
As used in this section and RCW 48.46.066, "health benefit plan,"
"basic health plan," "adjusted community rate," "small
employer," and "wellness activities" mean the same as defined in
RCW 48.43.005.
Sec.
6. RCW
48.46.066 and 1995 c 265 s 18 are each amended to read as follows:
(1)(a)
A health maintenance organization offering any health benefit plan to a small
employer shall offer and actively market to the small employer a health benefit
plan providing benefits identical to the schedule of covered health services
that are required to be delivered to an individual enrolled in the basic health
plan. Nothing in this subsection shall preclude a health maintenance
organization from offering, or a small employer from purchasing, other health
benefit plans that may have more or less comprehensive benefits than the basic
health plan, provided such plans are in accordance with this chapter. A health
maintenance organization offering a health benefit plan that does not include
benefits in the basic health plan shall clearly disclose these differences to
the small employer in a brochure approved by the commissioner.
(b)
A health benefit plan shall provide coverage for hospital expenses and services
rendered by a physician licensed under chapter 18.57 or 18.71 RCW but is not
subject to the requirements of RCW 48.46.275, 48.46.280, 48.46.285, 48.46.290,
48.46.350, 48.46.355, 48.46.375, 48.46.440, 48.46.480, 48.46.510, 48.46.520,
and 48.46.530 if: (i) The health benefit plan is the mandatory offering under
(a) of this subsection that provides benefits identical to the basic health
plan, to the extent these requirements differ from the basic health plan; or
(ii) the health benefit plan is offered to employers with not more than
twenty-five employees.
(2)
Nothing in this section shall prohibit a health maintenance organization from
offering, or a purchaser from seeking, benefits in excess of the basic health
plan services. All forms, policies, and contracts shall be submitted for
approval to the commissioner, and the rates of any plan offered under this
section shall be reasonable in relation to the benefits thereto.
(3)
Premium rates for health benefit plans for small employers as defined in this
section shall be subject to the following provisions:
(a)
The health maintenance organization shall develop its rates based on an
adjusted community rate and may only vary the adjusted community rate for:
(i)
Geographic area;
(ii)
Family size;
(iii)
Age; and
(iv)
Wellness activities.
(b)
The adjustment for age in (a)(iii) of this subsection may not use age brackets
smaller than five-year increments, which shall begin with age twenty and end
with age sixty-five. Employees under the age of twenty shall be treated as
those age twenty.
(c)
The health maintenance organization shall be permitted to develop separate
rates for individuals age sixty-five or older for coverage for which medicare
is the primary payer and coverage for which medicare is not the primary payer.
Both rates shall be subject to the requirements of this subsection (3).
(d)
The permitted rates for any age group shall be no more than four hundred
twenty-five percent of the lowest rate for all age groups on January 1, 1996,
four hundred percent on January 1, 1997, and three hundred seventy-five percent
on January 1, 2000, and thereafter.
(e)
A discount for wellness activities shall be permitted to reflect actuarially
justified differences in utilization or cost attributed to such programs not to
exceed twenty percent.
(f)
The rate charged for a health benefit plan offered under this section may not
be adjusted more frequently than annually except that the premium may be
changed to reflect:
(i)
Changes to the enrollment of the small employer;
(ii)
Changes to the family composition of the employee;
(iii)
Changes to the health benefit plan requested by the small employer; or
(iv)
Changes in government requirements affecting the health benefit plan.
(g)
The frequency of filing of rate adjustments for new and renewing small
employers is limited to once every six months.
(((g)))
(h) Rating factors shall produce premiums for identical groups that
differ only by the amounts attributable to plan design, with the exception of
discounts for health improvement programs.
(((h)))
(i) For the purposes of this section, a health benefit plan that
contains a restricted network provision shall not be considered similar
coverage to a health benefit plan that does not contain such a provision,
provided that the restrictions of benefits to network providers result in substantial
differences in claims costs. This subsection does not restrict or enhance the
portability of benefits as provided in RCW 48.43.015.
(((i)))
(j) Adjusted community rates established under this section shall pool
the medical experience of all groups purchasing coverage.
(4)
The health benefit plans authorized by this section that are lower than the
required offering shall not supplant or supersede any existing policy for the
benefit of employees in this state. Nothing in this section shall restrict the
right of employees to collectively bargain for insurance providing benefits in
excess of those provided herein.
(5)(a)
Except as provided in this subsection, requirements used by a health
maintenance organization in determining whether to provide coverage to a small
employer shall be applied uniformly among all small employers applying for
coverage or receiving coverage from the carrier.
(b)
A health maintenance organization shall not require a minimum participation
level greater than:
(i)
One hundred percent of eligible employees working for groups with three or less
employees; and
(ii)
Seventy-five percent of eligible employees working for groups with more than
three employees.
(c)
In applying minimum participation requirements with respect to a small
employer, a small employer shall not consider employees or dependents who have
similar existing coverage in determining whether the applicable percentage of
participation is met.
(d)
A health maintenance organization may not increase any requirement for minimum
employee participation or modify any requirement for minimum employer
contribution applicable to a small employer at any time after the small
employer has been accepted for coverage.
(6)
A health maintenance organization must offer coverage to all eligible employees
of a small employer and their dependents. A health maintenance organization
may not offer coverage to only certain individuals or dependents in a small
employer group or to only part of the group. A health maintenance organization
may not modify a health plan with respect to a small employer or any eligible
employee or dependent, through riders, endorsements or otherwise, to restrict
or exclude coverage or benefits for specific diseases, medical conditions, or
services otherwise covered by the plan.
NEW SECTION. Sec. 7. If
specific funding in the amount of two hundred six thousand dollars for the
purposes of this act, referencing this act by bill or chapter number, is not
provided by June 30, 1997, in the omnibus appropriations act, this act is null
and void.
