Administrative Code

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Virginia Administrative Code
Title 14. Insurance
Agency 5. State Corporation Commission, Bureau of Insurance
Chapter 211. Rules Governing Health Maintenance Organizations

14VAC5-211-70. Continuation of coverage.

A. An enrollee whose eligibility for coverage terminates under the group contract shall have the opportunity to continue coverage under the existing group contract for a period of at least 12 months immediately following the date of termination of the enrollee's eligibility for coverage under the group contract. Continuation coverage shall not be applicable if the group contract holder is required by federal law to provide for continuation of coverage under its group health plan pursuant to the Consolidated Omnibus Budget Reconciliation Act (COBRA) (P.L. 99-272). Coverage shall be provided without additional evidence of insurability subject to the following requirements:

1. The application and payment for the continued coverage is made to the group contract holder within 31 days after issuance of the written notice required in subsection C of this section, but in no event beyond the 60-day period following the date of the termination of the person's eligibility;

2. Each premium for the continued coverage is timely paid to the group contract holder on a monthly basis during the 12-month period; and

3. The premium for continuing the group coverage shall be at the health care plan's current rate applicable to similarly situated individuals under the group contract plus any applicable administrative fee not to exceed 2.0% of the current rate.

B. A continuation of coverage shall not be required to be made available when:

1. The enrollee is covered by or is eligible for benefits under Title XVIII of the Social Security Act (42 USC § 1395 et seq.) known as Medicare;

2. The enrollee is covered by substantially the same level of benefits under any policy, contract, or plan for individuals in a group;

3. The enrollee has not been continuously covered during the three-month period immediately preceding the enrollee's termination of coverage;

4. The enrollee was terminated by the health care plan for any of the reasons stated in 14VAC5-211-230 A 1 or 2, or coverage was rescinded; or

5. The enrollee was terminated from a plan administered by the Department of Medical Assistance Services that provided benefits pursuant to Title XIX or XXI of the Social Security Act (42 USC § 1396 et seq. or § 1397aa et seq.).

C. The group contract holder shall provide each enrollee or other person covered under the group contract written notice of the procedures and timeframes for obtaining continuation of coverage under the group contract. The notice shall be provided within 14 days of the group contract holder's knowledge of the enrollee's or other covered person's loss of eligibility under the group contract.

Statutory Authority

§§ 12.1-13 and 38.2-223 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 21, Issue 23, eff. July 1, 2005; amended, Virginia Register Volume 27, Issue 2, eff. January 1, 2011; Volume 27, Issue 25, eff. September 1, 2011; Volume 31, Issue 3, eff. January 1, 2015.

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