Mississippi Administrative Code › Title 19 - Department of Insurance › Part 1 - General › Chapter 26 - (2000-5) Compliance with Health Insurance Portability and Accountability Act of 1996 › Rule 19-1-26.05 - Small Group Market Requirements

Current through June 25, 2024
A. Guaranteed
				Availability of Coverage in the Small Group Market
At 42 U.S.C. § 300gg-11(a), (c), (d), (e) and (f), HIPAA
				  requires health insurance issuers that offer coverage in the small group market
				  to accept every small employer that applies for coverage, including every
				  eligible individual of the small employer. These provisions also prescribe
				  special rules for network plans, apply certain financial capacity limits and
				  set forth limited exceptions. At 45 C.F.R. § 146.150, HIPAA regulations
				  clarify that health insurance issuers in the small group market generally must
				  offer to each small employer all products that are approved for sale in the
				  small group market and that the issuer is actively marketing, and must accept
				  any small employer that applies for any of those products. Every health
				  insurance issuer which offers coverage in the small group market in the State
				  of Mississippi shall fully comply with the provisions of 42 U.S.C. §
				  300gg-11(a), (c), (d), (e) and (f) and 45 C.F.R. § 146.150.
B. Prohibition against
				Discrimination within Small Groups
At 42 U.S.C. § 300gg-1, and at 45 C.F.R. § 146.121,
				  HIPAA bars health insurance issuers that offer coverage in the small group
				  market from establishing rules for eligibility that are based on health
				  status-related factors, and from requiring individuals within small groups to
				  pay a higher premium or contribution than would a similarly situated
				  individual, based on a health status-related factor. Every health insurance
				  issuer which offers coverage in the small group market in the State of
				  Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg-1,
				  and 45 C.F.R. § 146.121.
C. Preexisting Condition Exclusions
1. Miss. Code Ann. §
										83-9-49(1)(Rev.
				1999) permits health insurance issuers in the small group market to apply
				preexisting condition limitations which do not contain a definition of a
				preexisting condition more restrictive than the following:
a. A condition that would have caused an
				ordinary prudent person to seek medical advice, diagnosis, care or treatment
				during the six (6) months immediately preceding the effective date of
				coverage;
b. A condition for which
				medical advice, diagnosis, care or treatment was recommended or received during
				the six (6) months immediately preceding the effective date of coverage.
At 42 U.S.C. § 300gg(a) and 45 C.F.R. §
				  146.111(a)(1)(i), HIPAA provides that a preexisting condition exclusion in a
				  policy issued in the small group market can only relate to a condition,
				  regardless of its cause, for which medical advice, diagnosis, care or treatment
				  was recommended or received within the 6-month period ending on the enrollment
				  date. Unlike Miss. Code Ann. §
												83-9-49(1)
				  (b)(Rev. 1999), there is no provision under
				  HIPAA allowing a health insurance issuer in the small group market to apply a
				  preexisting condition limitation for a condition that would have caused an
				  ordinary prudent person to seek medical advice, diagnosis, care or treatment
				  during the six (6) months immediately preceding the effective date of
				  coverage.
Every health insurance issuer which offers coverage in the
				  small group market in the State of Mississippi shall fully comply with the
				  provisions of 42 U.S.C. § 300gg(a) and 45 C.F.R. § 146.111(a)(1)(i),
				  which limit the definition of a preexisting condition to "a condition (whether
				  physical or mental), regardless of the cause of the condition, for which
				  medical advice, diagnosis, care, or treatment was recommended or received
				  within the 6-month period ending on the enrollment date."