
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC300gg-11]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                    CHAPTER 6A--PUBLIC HEALTH SERVICE
 
   SUBCHAPTER XXV--REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE
 
                      Part A--Group Market Reforms
 
    subpart 3--provisions applicable only to health insurance issuers
 
Sec. 300gg-11. Guaranteed availability of coverage for employers 
        in group market
        

(a) Issuance of coverage in small group market

                           (1) In general

        Subject to subsections (c) through (f) of this section, each 
    health insurance issuer that offers health insurance coverage in the 
    small group market in a State--
            (A) must accept every small employer (as defined in section 
        300gg-91(e)(4) of this title) in the State that applies for such 
        coverage; and
            (B) must accept for enrollment under such coverage every 
        eligible individual (as defined in paragraph (2)) who applies 
        for enrollment during the period in which the individual first 
        becomes eligible to enroll under the terms of the group health 
        plan and may not place any restriction which is inconsistent 
        with section 300gg-1 of this title on an eligible individual 
        being a participant or beneficiary.

                 (2) ``Eligible individual'' defined

        For purposes of this section, the term ``eligible individual'' 
    means, with respect to a health insurance issuer that offers health 
    insurance coverage to a small employer in connection with a group 
    health plan in the small group market, such an individual in 
    relation to the employer as shall be determined--
            (A) in accordance with the terms of such plan,
            (B) as provided by the issuer under rules of the issuer 
        which are uniformly applicable in a State to small employers in 
        the small group market, and
            (C) in accordance with all applicable State laws governing 
        such issuer and such market.

(b) Assuring access in large group market

                         (1) Reports to HHS

        The Secretary shall request that the chief executive officer of 
    each State submit to the Secretary, by not later December 31, 2000, 
    and every 3 years thereafter a report on--
            (A) the access of large employers to health insurance 
        coverage in the State, and
            (B) the circumstances for lack of access (if any) of large 
        employers (or one or more classes of such employers) in the 
        State to such coverage.

                  (2) Triennial reports to Congress

        The Secretary, based on the reports submitted under paragraph 
    (1) and such other information as the Secretary may use, shall 
    prepare and submit to Congress, every 3 years, a report describing 
    the extent to which large employers (and classes of such employers) 
    that seek health insurance coverage in the different States are able 
    to obtain access to such coverage. Such report shall include such 
    recommendations as the Secretary determines to be appropriate.

    (3) GAO report on large employer access to health insurance 
                                  coverage

        The Comptroller General shall provide for a study of the extent 
    to which classes of large employers in the different States are able 
    to obtain access to health insurance coverage and the circumstances 
    for lack of access (if any) to such coverage. The Comptroller 
    General shall submit to Congress a report on such study not later 
    than 18 months after August 21, 1996.

(c) Special rules for network plans

                           (1) In general

        In the case of a health insurance issuer that offers health 
    insurance coverage in the small group 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 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 because of 
            its obligations to existing group contract holders and 
            enrollees, and
                (ii) it is applying this paragraph uniformly to all 
            employers without regard to the claims experience of those 
            employers and their employees (and their dependents) or any 
            health status-related factor relating to such employees and 
            dependents.

           (2) 180-day suspension upon denial of coverage

        An issuer, upon denying health insurance coverage in any service 
    area in accordance with paragraph (1)(B), may not offer coverage in 
    the small group market within such service area for a period of 180 
    days after the date such coverage is denied.

(d) Application of financial capacity limits

                           (1) In general

        A health insurance issuer may deny health insurance coverage in 
    the small group 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 
        in the small group market in the State consistent with 
        applicable State law and without regard to the claims experience 
        of those employers and their employees (and their dependents) or 
        any health status-related factor relating to such employees and 
        dependents.

           (2) 180-day suspension upon denial of coverage

        A health insurance issuer upon denying health insurance coverage 
    in connection with group health plans in accordance with paragraph 
    (1) in a State may not offer coverage in connection with group 
    health plans in the small group market in the State for a period of 
    180 days after the date such coverage is denied or until the issuer 
    has demonstrated to the applicable State authority, if required 
    under applicable State law, that the issuer has sufficient financial 
    reserves to underwrite additional coverage, whichever is later. An 
    applicable State authority may provide for the application of this 
    subsection on a service-area-specific basis.

(e) Exception to requirement for failure to meet certain minimum 
        participation or contribution rules

                           (1) In general

        Subsection (a) of this section shall not be construed to 
    preclude a health insurance issuer from establishing employer 
    contribution rules or group participation rules for the offering of 
    health insurance coverage in connection with a group health plan in 
    the small group market, as allowed under applicable State law.

                          (2) Rules defined

        For purposes of paragraph (1)--
            (A) the term ``employer contribution rule'' means a 
        requirement relating to the minimum level or amount of employer 
        contribution toward the premium for enrollment of participants 
        and beneficiaries; and
            (B) the term ``group participation rule'' means a 
        requirement relating to the minimum number of participants or 
        beneficiaries that must be enrolled in relation to a specified 
        percentage or number of eligible individuals or employees of an 
        employer.

(f) Exception for coverage offered only to bona fide association members

    Subsection (a) of this section shall not apply to health insurance 
coverage offered by a health insurance issuer if such coverage is made 
available in the small group market only through one or more bona fide 
associations (as defined in section 300gg-91(d)(3) of this title).

(July 1, 1944, ch. 373, title XXVII, Sec. 2711, as added Pub. L. 104-
191, title I, Sec. 102(a), Aug. 21, 1996, 110 Stat. 1962.)


                            Prior Provisions

    A prior section 2711 of act July 1, 1944, was successively 
renumbered by subsequent acts and transferred, see section 238j of this 
title.


                             Effective Date

    Section applicable with respect to group health plans, and health 
insurance coverage offered in connection with group health plans, for 
plan years beginning after June 30, 1997, except as otherwise provided, 
see section 102(c) of Pub. L. 104-191, set out as a note under section 
300gg of this title.

                  Section Referred to in Other Sections

    This section is referred to in section 300gg-12 of this title.
