(a) A health insurer shall not be required to offer an individual health benefit plan or accept applications for the plan pursuant to Section 10965.3 in the case of any of the following:
(1) To an individual who does not live or reside within the insurer’s approved service areas.
(2) (A) Within a specific service area or portion of a service area, if the insurer reasonably anticipates and demonstrates to the satisfaction of the commissioner both of the following:
(i) It will not have sufficient health care delivery resources to ensure that health care services will be available and accessible to the individual because of its obligations to existing insureds.
(ii) It is applying this subparagraph uniformly to all individuals without regard to the claims experience of those individuals or any health status-related factor relating to those individuals.
(B) A health insurer that cannot offer an individual health benefit plan to individuals because it is lacking in sufficient health care delivery resources within a service area or a portion of a service area pursuant to subparagraph (A) shall not offer an individual health benefit plan in that area until the later of the following dates:
(i) The 181st day after the date coverage is denied pursuant to this paragraph.
(ii) The date the insurer notifies the commissioner that it has the ability to deliver services to individuals, and certifies to the commissioner that from the date of the notice it will enroll all individuals requesting coverage in that area from the insurer.
(C) Subparagraph (B) shall not limit the insurer’s ability to renew coverage already in force or relieve the insurer of the responsibility to renew that coverage as described in Section 10273.6.
(D) Coverage offered within a service area after the period specified in subparagraph (B) shall be subject to this section.
(b) (1) A health insurer may decline to offer an individual health benefit plan to an individual if the insurer demonstrates to the satisfaction of the commissioner both of the following:
(A) It does not have the financial reserves necessary to underwrite additional coverage. In determining whether this subparagraph has been satisfied, the commissioner shall consider, but not be limited to, the insurer’s compliance with the requirements of this part and the rules adopted thereunder.
(B) It is applying this subdivision uniformly to all individuals without regard to the claims experience of those individuals or any health status-related factor relating to those individuals.
(2) A health insurer that denies coverage to an individual under paragraph (1) shall not offer coverage before the later of the following dates:
(A) The 181st day after the date coverage is denied pursuant to this subdivision.
(B) The date the insurer demonstrates to the satisfaction of the commissioner that the insurer has sufficient financial reserves necessary to underwrite additional coverage.
(3) Paragraph (2) shall not limit the insurer’s ability to renew coverage already in force or relieve the insurer of the responsibility to renew that coverage as described in Section 10273.6. Coverage offered within a service area after the period specified in paragraph (2) shall be subject to this section.
(c) This chapter shall not be construed to limit the commissioner’s authority to develop and implement a plan of rehabilitation for a health insurer whose financial viability or organizational and administrative capacity has become impaired, to the extent permitted by PPACA.
(d) This section shall not apply to an individual health benefit plan that is a grandfathered plan.
(Amended by Stats. 2014, Ch. 71, Sec. 105. (SB 1304) Effective January 1, 2015.)
Last modified: October 25, 2018