(a) As used in this Code section, the term:
(1) "Group contract or group plan" is synonymous with the term "contract or plan" and means:
(A) A group contract of the type issued by a nonprofit medical service corporation established under Chapter 18 of this title;
(B) A group contract of the type issued by a nonprofit hospital service corporation established under Chapter 19 of this title;
(C) A group contract of the type issued by a health care plan established under Chapter 20 of this title;
(D) A group contract of the type issued by a health maintenance organization established under Chapter 21 of this title; or
(E) A group accident and sickness insurance policy or contract, as defined in Chapter 30 of this title.
(2) "Group member" means a person who has been a member of the group for at least six months; who is entitled to medical benefits coverage under a group contract or group plan; and who is an insured, certificate holder, or subscriber under the contract or plan.
(3) "Insurer" means an insurance company, nonprofit hospital service corporation, medical service nonprofit corporation, health care plan, or health maintenance organization.
(4) "Internal Revenue Code" means the federal Internal Revenue Code as defined in Code Section 48-1-2.
(5) "Plan administrator" means:
(A) The person designated as the plan administrator by the instrument under which the group contract or plan is operated; or
(B) If no plan administrator is designated, the plan sponsor. (b)(1) A group contract or plan providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, which is issued, delivered, issued for delivery, or renewed in this state to provide coverage for the employees of an employer subject to the provisions of Section 4980B of the Internal Revenue Code, shall contain a provision that a group member whose insurance under the contract or plan otherwise terminates after the expiration of the period of continuation of coverage for which the individual is eligible under Code Section 33-24-21.1 or Section 4980B of the Internal Revenue Code shall be entitled to continue coverage under that group contract or plan for himself or herself and his or her eligible dependents if the group member was 60 years of age or older as of the date on which the continuation of coverage afforded under Code Section 33-24-21.1 or Section 4980B of the Internal Revenue Code commences.
(2) A group member shall not be entitled to have coverage continued under paragraph (1) of this subsection if:
(A) Termination of employment is voluntary for other than health reasons;
(B) Termination of coverage occurred because the employment of a group member was terminated for reasons which would cause a forfeiture of unemployment compensation under Chapter 8 of Title 34, the "Employment Security Law";
(C) Termination of coverage occurred because the group member failed to pay any required contribution;
(D) Any discontinued coverage is immediately replaced by similar group coverage; or
(E) The group contract or group plan was terminated in its entirety or was terminated with respect to a class to which the group member belonged.
This paragraph shall not affect conversion rights available to a group member under any contract or plan.
(c) A group contract or plan providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases which is issued, delivered, issued for delivery, or renewed in this state to provide coverage for the employees of an employer subject to the provisions of Section 4980B of the federal Internal Revenue Code, shall contain a provision that:
(1) The surviving spouse of a group member may continue coverage under the plan, at the death of the group member, with respect to the spouse and any dependent children whose coverage under the plan otherwise would terminate because of the death of the group member if the surviving spouse is 60 years of age or older at the time of the death; and
(2) The divorced spouse of a group member may continue coverage under the plan, upon dissolution of marriage with the group member, with respect to the divorced spouse and any dependent children whose coverage under the plan otherwise would terminate because of the dissolution of marriage, if the divorced spouse is 60 years of age or older at the time of the dissolution or legal separation.
(d) Each group certificate issued to each group member shall set forth the continuation right provided in subsections (b) and (c) of this Code section in a separate provision bearing its own caption. The provision shall clearly set forth a full description or the continuation right available, including all requirements, limitations, exceptions, the premium required or a brief statement concerning the method of calculation thereof, and the time of payment of all premiums due during the period of continuation.
(e) In the event and to the extent that this Code section is applicable, the election by the group member or divorced or surviving spouse to obtain continuation of coverage as provided under the provisions of Section 4980B of the Internal Revenue Code or under the provisions of Code Section 33-24-21.1 shall constitute election of continuation of coverage under this Code section without further action by the group member or surviving or divorced spouse. The provisions of Section 4980B of the Internal Revenue Code or of Code Section 33-24-21.1, whichever is applicable, regarding notice to a group member or a divorced or surviving spouse of the right to continue coverage shall apply to the continuation of coverage provided under this Code section.
(f) If an eligible group member or the divorced or surviving spouse elects continuation of coverage under subsection (b) or (c) of this Code section:
(1) The monthly premium for the continuation shall not be greater than 120 percent of the total of the amount that would be charged if the eligible group member or the divorced or surviving spouse were a current group member and the amount that the group policyholder would contribute toward the premium if the eligible group member or the divorced or surviving spouse were a current group member;
(2) The first premium for the continuation of coverage under this Code section shall be paid by the eligible group member or the divorced or surviving spouse on the first regular due date following the expiration of the eligible person's benefits under the provisions of Code Section 33-24-21.1 or Section 4980B of the Internal Revenue Code; and
(3) The right to continuation of coverage shall terminate upon the earliest of any of the following:
(A) The failure to pay premiums or required premium contributions, if applicable, when due, including any grace period allowed by the policy;
(B) The date that the group plan is terminated as to all group members, except that if a different group plan is made available to group members, the eligible group member or the divorced or surviving spouse shall be eligible for continuation of the same coverage under the new plan;
(C) The date on which the eligible group member or divorced or surviving spouse becomes insured under any other group health plan; or
(D) The date on which the eligible group member or the divorced or surviving spouse becomes eligible for federal medicare coverage.
(g) This Code section shall apply to any group contract or group plan which covers 20 or more employees and which is issued, delivered, issued for delivery, or renewed in this state on or after July 1, 1992, and to any group contract or group plan covering 20 or more employees then in effect on the first anniversary date occurring on or after July 1, 1992.
Section: Previous 33-24-17 33-24-18 33-24-19 33-24-19.1 33-24-20 33-24-21 33-24-21.1 33-24-21.2 33-24-22 33-24-23 33-24-24 33-24-25 33-24-26 33-24-26.1 33-24-27 NextLast modified: October 14, 2016