2012 Delaware Code
Title 18 - Insurance Code
CHAPTER 36. INDIVIDUAL HEALTH INSURANCE MINIMUM STANDARDS
§ 3607. Limited guaranteed issue.

(a) Every carrier offering individual health benefit plans in Delaware shall offer and accept for enrollment, pursuant to subsection (b) of this section, every federally eligible individual who applies for coverage within 63 days after termination of such individual's prior coverage, except that this requirement shall not apply to carriers offering coverage only through bona fide associations or to carriers offering individual coverage only through conversion policies.

(b) A carrier shall meet the requirements of subsection (a) of this section if:

(1) The carrier offers at least 2 different health benefit policy forms, both of which are designed for, are made generally available and actively marketed to and enroll both federally eligible and other individuals; and

(2) The offering of policy forms includes, at a minimum:

a. The policy forms for health benefit plan coverage with the largest and next to largest premium volume of all such policy forms offered by the carrier in Delaware; or

b. A lower-level coverage policy form and a higher-level coverage policy form which include benefits substantially similar to other individual health insurance coverage offered by the carrier in Delaware and are covered under a risk adjustment, risk spreading or financial subsidization method. As used in this subparagraph:

1. "Higher-level coverage" means a policy form for which the actuarial value of the benefits under the coverage is at least 15 percent greater than the actuarial value of lower-level coverage offered by the carrier in Delaware and the actuarial value of the benefits under the coverage is at least 100 percent but not greater than 120 percent of the policy form weighted average.

2. "Lower-level coverage" means a policy form for which the actuarial value of the benefits under the coverage is at least 85 percent but not greater than 100 percent of the policy form weighted average.

3. "Policy form weighted average" means the average actuarial value of the benefits provided by all the health insurance coverage issued (as elected by the carrier) either by that carrier or, if such data are available, by all carriers in Delaware in the individual health benefit plan market during the previous year (not including coverage issued under this section) weighted by enrollment for the different coverage.

c. Preexisting condition limitations shall not be applied to federally eligible individuals for coverage provided pursuant to this section.

(c) With respect to the provisions of subsection (b) of this section, a carrier that offers coverage in the individual market through a network plan may limit the individuals who may be enrolled to those that live, reside or work within the service area of the plan. Such a carrier may deny coverage to eligible individuals if it demonstrates to the Commissioner that it will not have the capacity to deliver services adequately to additional enrollees and it is applying this subsection uniformly to individuals without regard to any health status-related factor of such individuals and without regard to whether the individuals are eligible individuals.

(d) A carrier may apply to the Commissioner to suspend, for a period of time, its duty to issue coverage pursuant to subsection (b) of this section where continued compliance would adversely affect the financial condition of the company. Where such a suspension is granted, the carrier may not offer coverage in the individual market for a period of at least 180 days after the suspension is granted.

(e) For the purposes of this section, the term "health benefit plan" as defined in § 3602(10) of this title does not include nonrenewable short-term individual health benefit plans with a duration of 6 months or less.

71 Del. Laws, c. 143, § 3; 72 Del. Laws, c. 383, § 3.;