3901-8-14 Open enrollment for children under nineteen in the individual and non-employer group markets.

(A) Purpose

The purpose of this rule is to establish uniform open enrollment periods during which carriers in the individual health insurance market may offer coverage to children under nineteen years of age on a guaranteed issue basis without any limitations or restrictions based on the health status of the child. For the purpose of this rule, "carrier" has the same meaning as defined in division (D) of section 3924.01 of the Revised Code.

(B) Authority

This rule is promulgated pursuant to the authority vested in the superintendent under sections 3901.041 and 3901.044 of the Revised Code.

(C) Application of this rule to basic and standard coverage sold in the individual market

This rule does not apply to the requirements imposed on carriers or coverage issued pursuant to section 3923.58 or 3923.581 of the Revised Code. For purposes of this rule, the term "non-grandfathered coverage" means coverage offered by a carrier in the individual market to an applicant under the age of nineteen which is not the basic or standard plans offered pursuant to section 3923.58 or 3923.58 1 of the Revised Code.

(D) Qualifying event

Carriers offering non-grandfathered coverage in the individual market to children under age nineteen who become newly eligible as a result of a qualifying event, shall make such coverage available on a guaranteed issue basis, without any limitations or restrictions based on the health status of the child for a period of thirty days following the qualifying event. For purposes of this rule, a qualifying event shall include birth, adoption, marriage or involuntary loss of other coverage for any reason other than fraud, misrepresentation or failure to pay the premium.

(E) Annual open enrollment for new applicants

(1) Beginning March 2011, carriers offering non-grandfathered coverage in the individual market shall hold an annual open enrollment period each March, for the entire month, at which time coverage will be available for new applicants under age nineteen on a guaranteed issue basis, without any limitations or restrictions based on the health status of the child.

(2) Notice of the open enrollment opportunity for new applicants, as well as the opportunity to enroll due to a qualifying event, must be displayed prominently on the carrier's web site throughout the year.

(F) Enrollment opportunity at renewal for children eligible as dependents

(1) With respect to family policies being renewed, carriers must provide non-grandfathered policyholders in the individual market an opportunity to enroll eligible children for guaranteed issue coverage, without limitations or restrictions based on the health status of the child, beginning no later than the first day of the first policy year on or after the effective date of this rule. This enrollment opportunity must continue for at least thirty days and be offered each year at the same time.

(2) Written notice of the annual open enrollment opportunity, as well as the opportunity to enroll due to a qualifying event, must be provided to policyholders in a timely manner and may be included in other enrollment materials distributed to policyholders, provided the statement is prominent.

(3) Coverage under paragraphs (D), (E) and (F) of this rule shall become effective on the first day of the month following the receipt of the completed application, or a date mutually agreed upon by the applicant and the carrier, but no later than forty-five days after the last day of the month of the open enrollment period in which the application was received.

(G) Carriers may guarantee issue coverage to children under nineteen throughout the year

Carriers that issue non-grandfathered coverage in the individual market on a guaranteed issue basis without limitations or restrictions based on the health status of the child throughout the year need not follow the requirements of paragraph (E) of this rule with respect to such coverage. In applying this paragraph, a carrier that chooses to offer non-grandfathered family coverage that includes coverage of dependent children under the age of nineteen throughout the year may also decide to offer child-only policies during the enrollment periods set forth in this rule.

(H) Underwriting practices to remain the same outside of open enrollment

To the extent permitted by federal law, carriers may continue with current underwriting practices in the non-grandfathered individual market with respect to children outside of the open enrollment periods established in this rule.

(I) Notice of withdrawal from the child-only market

(1) With respect to carriers that offer non-grandfathered coverage in the individual market to applicants under the age of nineteen after the effective date of this rule, in order for such a carrier to discontinue offering such coverage to such applicants, the carrier must first deliver written notice to the superintendent at least forty-five days in advance of the date that such discontinuance will occur. The notice shall identify the carrier, state the carrier's intent to discontinue offering such coverage to such applicants, identify the date on which the discontinuance will occur, and include the name, address and telephone number of contact person for the carrier.

(2) Upon receipt of such notice from a carrier, the superintendent shall notify other carriers writing coverage in Ohio's individual market that the superintendent has received such notice.

(3) Notwithstanding paragraph (I)(1) of this rule, if one carrier delivers notice in accordance with paragraph (I)(1) of this rule, another carrier may discontinue offering non-grandfathered coverage in the individual market to applicants under the age of nineteen as of the date of discontinuance for the initial carrier, if such other carrier delivers written notice to the superintendent no more than fifteen days after the superintendent notifies carriers of receipt of the initial notice in accordance with paragraph (I)(2) of this rule. Written notice under this paragraph shall contain the same information as applicable to a notice provided under paragraph (I)(1) of this rule.

(J) Surcharge for lapse in coverage

A carrier writing non-grandfathered coverage in the individual market to applicants under the age of nineteen may apply a surcharge to any applicant with a gap in coverage of more than sixty-three days immediately prior to the applicant's purchase of coverage, provided that the surcharge is reflected in the rates filed with the department and is actuarially justified.

(K) Ensuring enrollment is limited to open enrollment periods

A carrier writing family coverage in the individual market that includes coverage of dependents may cancel coverage for a dependent if the parent subscriber drops coverage and the coverage was purchased subsequent to the last open enrollment period held by the carrier in accordance with this rule. If such coverage for a dependent is cancelled, the carrier must allow the dependent to enroll in any available child-only policy during the next open enrollment period without assessing a surcharge for a lapse in coverage.

(L) Eligibility rules related to other coverage

With respect to non-grandfathered coverage offered in the individual market to applicants under the age of nineteen, carriers may limit enrollment to applicants not covered by or eligible for "Medicaid", the "Children's Health Insurance Program" (CHIP), "Medicare", or an employer-sponsored group health plan unless the applicant is without coverage at the time of enrollment because of an employer-sponsored group plan's mandatory initial waiting period.

(M) Monitoring coverage provided to children in Ohio

The superintendent shall collect information from carriers in Ohio's individual market as to the number of policies sold to applicants under the age of nineteen. This information shall be collected pursuant to the superintendent's authority under section 3901.48 of the Revised Code on an annual basis and shall be made available publicly on an aggregate basis.

(N) Severability

If any paragraph, term, or provision of this rule is adjudged invalid for any reason, the judgment shall not affect, impair, or invalidate any other paragraph, term, or provision of this rule, but the remaining paragraphs, terms, and provisions shall be and continue in full force and effect.

Replaces: 3901-8-14

R.C. 119.032 review dates: 01/08/2014 and 08/31/2018
Promulgated Under: 119.03
Statutory Authority: 3901.041 , 3901.044
Rule Amplifies: 3901.044
Prior Effective Dates: 9/27/2010 (Emer.), 12/26/2010