# Title 26.1 — Insurance

## Chapter 26.1-36.4 — Hospital and Medical Insurance

### § 26.1-36.4-01. Application and scope.

This chapter applies to all policies issued or renewed after July 31, 1995. The provisions of
chapter 26.1-36 apply when not in conflict with this chapter.
### § 26.1-36.4-02. Definitions.

As used in this chapter, the definitions in section 26.1-36.3-01 apply, unless the context
otherwise requires. In addition:
1. "Insurer" means any insurance company, nonprofit health service organization,
fraternal benefit society, or health maintenance organization that provides a plan of
health insurance or health benefits subject to state insurance regulation.
2. "Policy" means any health benefit plan as defined in section 26.1-36.3-01, whether
offered on a group or individual basis. The term does not include an individual
short-term limited-duration plan or association short-term limited-duration plan as
defined in section 26.1-36.8-01.
### § 26.1-36.4-03. Limits on pre-existing condition exclusions.

An insurer may impose a pre-existing condition exclusion only if:
1. The exclusion relates to a condition, regardless of the cause of the condition, for which
medical diagnosis, care, or treatment was recommended or received within the
six-month period ending on the effective date of the person's coverage.
2. The exclusion extends for a period of not more than twelve months after the effective
date of coverage. A group policy may impose an eighteen-month pre-existing condition
to a late enrollee, as the term late enrollee is defined in section 26.1-36.3-01.
### § 26.1-36.4-03.1. Additional limits on pre-existing condition exclusions.

A group policy may not impose a pre-existing condition exclusion that:
1. Relates to pregnancy as a pre-existing condition.
2. Treats genetic information as a pre-existing condition in the absence of a diagnosis of
a condition related to such information.
### § 26.1-36.4-04. Portability of insurance policies.

An insurer shall reduce any time period applicable to a pre-existing condition, for a policy by
the aggregate of periods the individual was covered by qualifying previous coverage, if the
qualifying previous coverage as defined in section 26.1-36.3-01 is continuous until at least
sixty-three days before the effective date of the new coverage. Any waiting period applicable to
an individual for coverage under a health benefit plan may not be taken into account in
determining the period of continuous coverage. Insurers shall credit coverage in the same
manner as provided by section 26.1-36.3-06 and the rules adopted by the commissioner
pursuant thereto.
### § 26.1-36.4-05. Renewability of health insurance coverage - Discrimination prohibited.

1. An insurer issuing policies or certificates under this chapter shall provide for the
renewability or continuability of coverage unless:
a. The individual or group has failed to pay premiums or contributions in accordance
with the terms of the health benefit plan or the insurer has not received timely
premium payments.
b. The individual or group has performed an act or practice that constitutes fraud or
made an intentional misrepresentation of a material fact under the terms of the
coverage.
c. Noncompliance with the insurer's minimum group participation requirements.
d. Noncompliance with the insurer's employer group contribution requirements.

e. A decision by the insurer to discontinue offering a particular type of health
insurance coverage in the group or individual market. A type of group health
benefit plan or individual policy may be discontinued by the insurer in that market
only if the insurer:
(1) Provides advance notice of its decision under this paragraph to the
commissioner in each state in which it is licensed;
(2) Provides notice of the decision not to renew coverage to all affected
individuals, employers, participants, beneficiaries, and to the commissioner
in each state in which an affected insured is known to reside at least ninety
days prior to the nonrenewal of any health benefit plans by the insurer.
Notice to the commissioner under this subdivision must be provided at least
three working days prior to the notice to the affected individuals, employers,
participants, and beneficiaries;
(3) Offers to each affected group or individual the option to purchase all other
health benefit plans or individual coverage currently being offered by the
insurer in that market; and
(4) In exercising the option to discontinue the particular type of group health
benefit plan or individual coverage and in offering the option of coverage
under paragraph 3, the insurer acts uniformly without regard to claims
experience or any health status-related factor relating to any affected
individuals, participants, or beneficiaries covered or new individuals,
participants, or beneficiaries who may become eligible for such coverage.
f. A decision by the insurer to discontinue offering and to nonrenew all its health
benefit plans or individual coverage delivered or issued for delivery to employers
or individuals in this state. In such a case, the insurer shall:
(1) Provide advance notice of its decision under this paragraph to the
commissioner in each state in which it is licensed;
(2) Provides notice of the decision not to renew coverage to all affected
individuals, employers, participants, and beneficiaries, and to the
commissioner in each state in which an affected insured is known to reside
at least one hundred eighty days prior to the nonrenewal of any health
benefit plans by the insurer. Notice to the commissioner under this
subdivision must be provided at least three working days prior to the notice
to the affected individuals, employers, participants, and beneficiaries; and
(3) Discontinue all health insurance issued or delivered for issuance in the
state's group or individual market and not renew such health coverage in
that market.
g. In the case of health benefit plans that are made available in the group or
individual market only through one or more associations, the membership of an
employer or individual in the association, on the basis of which the coverage is
provided, ceases, but only if the coverage is terminated under this paragraph
uniformly without regard to any health status-related factor relating to any
covered individual.
h. The commissioner finds that the continuation of the coverage would not be in the
best interests of the policyholders or certificate holders or would impair the
insurer's ability to meet its contractual obligations. In this case the commissioner
shall assist affected insureds in finding replacement coverage.
2. An insurer that elects not to renew a health benefit plan under subdivision f of
subsection 1 may not write new business in the applicable market in this state for a
period of five years from the date of notice to the commissioner.
3. In the case of an insurer doing business in one established geographic service area of
the state, this section only applies to the insurer's operations in that service area.
4. An insurer offering coverage through a network plan may not be required to offer
coverage or accept applications pursuant to subsection 1 or 2 in the case of the
following:

a. To an eligible person who no longer resides, lives, or works in the service area, or
in an area for which the insurer is authorized to do business, but only if coverage
is terminated under this subdivision uniformly without regard to any health
status-related factor; or
b. To an insurer that no longer has any enrollee in connection with the plan who
lives, resides, or works in the service area of the insurer, or the area for which the
insurer is authorized to do business.
5. At the time of coverage renewal, an insurer may modify the health insurance coverage
for a product offered to a group or individual, if the modification is reasonable,
consistent with state law, and effective on a uniform basis. If coverage is modified, the
carrier shall:
a. Provide advance notice of its decision under this subsection to the commissioner
at least three working days prior to mailing the notice to the affected employers
and participants and beneficiaries.
b. Provide notice of the decision to modify health coverage to all affected
employers, participants, and beneficiaries and the commissioner sixty days prior
to the modification of health coverage by the carrier.
### § 26.1-36.4-06. Modified community rating.

Premium rates for individual policies are subject to the following:
1. For any class of individuals, the premium rates charged during a rating period to the
individuals in that class for the same or similar coverage may not vary by a ratio of
more than six to one after August 1, 1995, and by a ratio of more than five to one after
August 1, 1996, when age, industry, gender, and duration of coverage of the
individuals are considered. Gender and duration of coverage may not be used as a
rating factor for policies issued after January 1, 1997.
2. An insurer, in addition to the factors set forth in subsection 1, may use geography,
family composition, healthy lifestyles, and benefit variations to determine premium
rates.
### § 26.1-36.4-07. Health benefits package required.

Repealed by S.L. 2013, ch. 236, § 6.
### § 26.1-36.4-08. Employer payment of employee premium.

An insurer shall accept a personal or business check from an employer as a payment
method for premium payment for an employee's individual accident and health insurance policy.
This section does not apply to groups as defined under chapter 26.1-36.3.
### § 26.1-36.4-09. Health insurance utilization reports.

1. Once each calendar year, any employer with fifty-one or more eligible employees, any
employer investigating becoming part of a health plan, including a plan sponsored by
an association or a multiple employer welfare arrangement, or any employer upon
termination of health insurance coverage, the employer is entitled to a report from the
insurer or administrator of that employer's employee health plan which includes:
a. Annual data for the previous three years on the premiums paid by the employer
and the claims paid by the insurer or administrator.
b. A current census of employees and dependents covered under the employer's
health plan.
2. Insurers shall provide the report pursuant to subsection 1 to an employer within thirty
days of receipt of a request for the information.
3. The information provided pursuant to subsection 1 may not identify specific employee
claims or other confidential health care information.
4. Upon notification of termination of health insurance before the end of a benefit period,
the terminated insurer, at the request of the employer and within thirty days of the
request, shall supply the succeeding or new insurer a report of all deductibles and

coinsurance payments for each employee covered by the employer's health insurance
plan for the most recent benefit period.
