【跨境合规】美国《健康保险便利和责任法案》（HIPPA）中英对照摘录（十三）

第 2742 条 个人健康保险保障的保证续保

(a) 一般规定

除本条另有规定外，承保个人健康保险的保险机构，应当根据投保人的选择，对保险予以续保或者维持保险效力。

(b) 法定不予续保的一般例外情形

保险机构仅可基于下列一项或多项事由，对个人保险市场项下投保人的保险拒绝续保或者终止保险效力：

未缴纳保费：投保人未按照保险合同约定缴纳保费 / 分摊费用，或者保险机构未按时收到保费。

保险欺诈：投保人实施欺诈行为，或者就保险项下重大事实作出故意虚假陈述。

保险产品整体停售：保险机构依据本条 (c) 款以及可适用的州法律，停止在个人保险市场提供该类保险产品。

迁出服务区域：如保险机构运营网络定点计划，投保人不再居住、生活或者工作于该保险的服务区域（或机构获准开展业务的区域）；但依据本项终止保险时，必须统一适用规则，不得基于被保险人的任何健康状况相关因素区别对待。

协会会员资格终止：保险产品仅通过合法协会向个人保险市场提供，投保人赖以投保的协会会员资格终止；依据本项终止保险时，必须统一适用规则，不得基于被保险人的任何健康状况相关因素区别对待。

(c) 保险整体终止的法定要求

(1) 停售某一类特定保险产品：保险机构决定停止在个人保险市场销售某一类保险产品，必须同时满足以下全部条件，才可以终止该类保单：

  (A) 至少在该类保险停售90 日之前，向持有该类保单的每一位被保险人发送停售通知；

  (B) 向原该类保单的全部投保人，提供购买本机构当前在该个人保险市场发售的其他个人健康保险产品的选择权；

  (C) 在决定停售该类产品、提供替代投保选择权的全过程中，统一适用规则，不区分已参保人员、潜在参保人员的健康状况相关因素。

(2) 全部个人保险业务退出市场

  (A) 一般规则：受本分项 (C) 约束，保险机构决定彻底退出某州全部个人保险市场业务，仅在同时满足以下条件时，才可终止保险：

    (i) 至少在保险到期180 日之前，向该州对应监管机关以及每一位投保人发出业务终止通知；

    (ii) 该州个人保险市场项下，该机构全部已签发、待签发的个人保险全部停止，不再续保本市场内任何该机构保单。

  (B) 市场禁入规则：保险机构依据 (A) 项完全退出某州个人保险市场的，自最后一份未续保保单终止之日起5 年内，不得再在该州该个人保险市场发售任何健康保险产品。

(d) 统一修改保险条款的例外

保险续保时，保险机构可以对同一保单文本下的保险责任进行修改；前提是该修改符合州法律，并且对持有该类保单的全部投保人统一生效。

(e) 仅通过协会销售的保险之适用规则

对于保险机构仅通过一家或多家协会向个人保险市场提供的保险，在适用本条规定时，条文中所称 “个人”，视为同时包含该个人所属的协会。

第 2743 条 参保证明出具义务

第 2701 (e) 条的各项规定，同样适用于保险机构在个人保险市场销售的健康保险，其适用效力，与适用于大小团体保险市场的团体配套保险产品完全一致。

SEC. 2742. GUARANTEED RENEWABILITY OF INDIVIDUAL HEALTH INSURANCE COVERAGE.

(a) IN GENERAL. — Except as provided in this section, a health insurance issuer that provides individual health insurance coverage to an individual shall renew or continue in force such coverage at the option of the individual.

(b) GENERAL EXCEPTIONS. — A health insurance issuer may nonrenew or discontinue health insurance coverage of an individual in the individual market based only on one or more of the following:

(1) NONPAYMENT OF PREMIUMS. — The individual has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the issuer has not received timely premium payments.

(2) FRAUD. — The individual has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.

(3) TERMINATION OF PLAN. — The issuer is ceasing to offer coverage in the individual market in accordance with subsection (c) and applicable State law.

(4) MOVEMENT OUTSIDE SERVICE AREA. — In the case of a health insurance issuer that offers health insurance coverage in the market through a network plan, the individual no longer resides, lives, or works in the service area (or in an area for which the issuer is authorized to do business) but only if such coverage is terminated under this paragraph uniformly without regard to any health status‑related factor of covered individuals.

(5) ASSOCIATION MEMBERSHIP CEASES. — In the case of health insurance coverage that is made available in the individual market only through one or more bona fide associations, the membership of the individual in the association (on the basis of which the coverage is provided) ceases but only if such coverage is terminated under this paragraph uniformly without regard to any health status‑related factor of covered individuals.

(c) REQUIREMENTS FOR UNIFORM TERMINATION OF COVERAGE.

(1) PARTICULAR TYPE OF COVERAGE NOT OFFERED. — In any case in which an issuer decides to discontinue offering a particular type of health insurance coverage offered in the individual market, coverage of such type may be discontinued by the issuer only if:

  (A) the issuer provides notice to each covered individual provided coverage of this type in such market of such discontinuation at least 90 days prior to the date of the discontinuation of such coverage;

  (B) the issuer offers to each individual in the individual market provided coverage of this type, the option to purchase any other individual health insurance coverage currently being offered by the issuer for individuals in such market; and

  (C) in exercising the option to discontinue coverage of this type and in offering the option of coverage under subparagraph (B), the issuer acts uniformly without regard to any health status‑related factor of enrolled individuals or individuals who may become eligible for such coverage.

(2) DISCONTINUANCE OF ALL COVERAGE.

  (A) IN GENERAL. — Subject to subparagraph (C), in any case in which a health insurance issuer elects to discontinue offering all health insurance coverage in the individual market in a State, health insurance coverage may be discontinued by the issuer only if:

    (i) the issuer provides notice to the applicable State authority and to each individual of such discontinuation at least 180 days prior to the date of the expiration of such coverage; and

    (ii) all health insurance issued or delivered for issuance in the State in such market are discontinued and coverage under such health insurance coverage in such market is not renewed.

  (B) PROHIBITION ON MARKET REENTRY. — In the case of a discontinuation under subparagraph (A) in the individual market, the issuer may not provide for the issuance of any health insurance coverage in the market and State involved during the 5‑year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.

(d) EXCEPTION FOR UNIFORM MODIFICATION OF COVERAGE. — At the time of coverage renewal, a health insurance issuer may modify the health insurance coverage for a policy form offered to individuals in the individual market so long as such modification is consistent with State law and effective on a uniform basis among all individuals with that policy form.

(e) APPLICATION TO COVERAGE OFFERED ONLY THROUGH ASSOCIATIONS. — In applying this section in the case of health insurance coverage that is made available by a health insurance issuer in the individual market to individuals only through one or more associations, a reference to an ‘‘individual’’ is deemed to include a reference to such an association (of which the individual is a member).

SEC. 2743. CERTIFICATION OF COVERAGE.

The provisions of section 2701(e) shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as it applies to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market.