42 USC 300gg-1 - Guaranteed availability of coverage

U.S Code last checked for updates: May 10, 2024

§ 300gg–1.

Guaranteed availability of coverage

(a)

Guaranteed issuance of coverage in the individual and group market

(b)

Enrollment

(1)

Restriction

(2)

Establishment

(3)

Regulations

(c)

Special rules for network plans

(1)

In general

In the case of a health insurance issuer that offers health insurance coverage in the group and individual market through a network plan, the issuer may—

(A)

limit the employers that may apply for such coverage to those with eligible individuals who live, work, or reside in the service area for such network plan; and

(B)

within the service area of such plan, deny such coverage to such employers and individuals if the issuer has demonstrated, if required, to the applicable State authority that—

(i)

it will not have the capacity to deliver services adequately to enrollees of any additional groups or any additional individuals because of its obligations to existing group contract holders and enrollees, and

(ii)

it is applying this paragraph uniformly to all employers and individuals without regard to the claims experience of those individuals, employers and their employees (and their dependents) or any health status-related factor relating to such individuals ¹ employees and dependents.

(2)

180-day suspension upon denial of coverage

(d)

Application of financial capacity limits

(1)

In general

A health insurance issuer may deny health insurance coverage in the group or individual market if the issuer has demonstrated, if required, to the applicable State authority that—

(A)

it does not have the financial reserves necessary to underwrite additional coverage; and

(B)

it is applying this paragraph uniformly to all employers and individuals in the group or individual market in the State consistent with applicable State law and without regard to the claims experience of those individuals, employers and their employees (and their dependents) or any health status-related factor relating to such individuals, employees and dependents.

(2)

180-day suspension upon denial of coverage

(July 1, 1944, ch. 373, title XXVII, § 2702, as added and amended Pub. L. 111–148, title I, §§ 1201(4), 1563(c)(8), formerly § 1562(c)(8), title X, § 10107(b)(1), Mar. 23, 2010, 124 Stat. 156, 266, 911.)

cite as: 42 USC 300gg-1