R590. Insurance, Administration.R590-269. Individual Open Enrollment Period.
R590-269-1. Authority.
This rule is promulgated by the commissioner pursuant to Sections 31A-2-201 and 31A-30-117.
R590-269-2. Purpose and Scope.
(1) The purpose of this rule is to establish an open enrollment period for an insurer that offers an individual health benefit plan outside the health insurance exchange.
(2) This rule applies to an individual carrier that offers an individual health benefit plan outside the health insurance exchange with an effective date on or after January 1, 2014.
R590-269-3. Definitions.
Terms used in this rule are defined in Sections 31A-1-301 and 31A-30-103. Additional terms are defined as follows:
(1)(a) "Loss of minimum essential coverage" means the circumstances described in 26 CFR 54.9801-6(a)(3)(i) through (iii).
(b) "Loss of minimum essential coverage" does not include termination or loss due to:
(i) failure to pay premiums on a timely basis, including COBRA premiums before the expiration of COBRA coverage; or
(ii) a situation allowing for a rescission as specified in 45 CFR 147.128.
(2) "Qualifying life event" means an event that triggers a special enrollment period because an individual or dependent:
(a) loses minimum essential coverage;
(b) gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption;
(c) is unintentionally, inadvertently, or erroneously enrolled or non-enrolled as a result of the error, misrepresentation, or inaction of an officer, employee, or agent of an exchange or the United States Department of Health and Human Services, or its instrumentalities as evaluated and determined by an exchange;
(d) demonstrates to the individual carrier that the health benefit plan in which the individual was enrolled substantially violated a material provision of its contract in relation to the enrollee;
(e) is newly ineligible for advance payment of premium tax credits; or
(f) permanently moves into a new service area.
R590-269-4. Open and Special Enrollment Periods.
(1)(a) The open enrollment period for an individual health benefit plan outside the health insurance exchange shall coincide with the open enrollment period for the health insurance exchange.
(b) Open enrollment period coverage begins on:
(i) January 1 for an individual who enrolls on or before December 15;
(ii) the first day of the following month, for an individual who enrolls between the first and the fifteenth of the month; and
(iii) the first day of the second following month for an individual who enrolls between the sixteenth and the last day of the month.
(2) An insurer shall offer an individual experiencing a qualifying life event a special enrollment period for at least 60 days.
(a) In the case of birth, adoption, or placement for adoption, the coverage is effective on the date of:
(i) birth;
(ii) adoption; or
(iii) placement for adoption.
(b) Coverage is effective on the first day of the month following the date the insurer receives the request for special enrollment when:
(i) an individual or dependent marries;
(ii) an individual or dependent loses minimum essential coverage;
(iii) an individual or dependent is unintentionally, inadvertently, or erroneously enrolled or non-enrolled as a result of the error, misrepresentation, or inaction of an officer, employee, or agent of an exchange or the United States Department of Health and Human Services, or its instrumentalities as evaluated and determined by an exchange;
(iv) an individual demonstrates to the insurer that the health benefit plan in which the individual was enrolled substantially violated a material provision of its contract regarding the enrollee; or
(v) an individual permanently moves into a new service area.
R590-269-5. Severability.
If any provision of this rule, Rule R590-269, or its application to any person or situation is held invalid, such invalidity does not affect any other provision or application of this rule that can be given effect without the invalid provision or application. The remainder of this rule shall be given effect without the invalid provision or application.
