689B.500 - Coverage of preexisting conditions; when health maintenance organization may require affiliation period.
689B.500 Coverage of preexisting conditions; when health maintenance organization may require affiliation period.
1. Except as otherwise provided in this section, a carrier that issues a group health plan or coverage under blanket accident and health insurance or group health insurance shall not deny, exclude or limit a benefit for a preexisting condition for:
(a) More than 12 months after the effective date of coverage if the employee or other insured enrolls through open enrollment or after the first day of the waiting period for that enrollment, whichever is earlier; or
(b) More than 18 months after the effective date of coverage for a late enrollee.
Ê A carrier may not define a preexisting condition more restrictively than that term is defined in NRS 689B.450.
2. The period of any exclusion for a preexisting condition imposed by a group health plan or coverage under blanket accident and health insurance or group health insurance on a person to be insured in accordance with the provisions of this chapter must be reduced by the aggregate period of creditable coverage of that person, if the creditable coverage was continuous to a date not more than 63 days before the effective date of the coverage. The period of continuous coverage must not include:
(a) Any waiting period for the effective date of the new coverage applied by the employer or the carrier; or
(b) Any affiliation period not to exceed 60 days for a new enrollee and 90 days for a late enrollee required before becoming eligible to enroll in the group health plan.
3. A health maintenance organization authorized to transact insurance pursuant to chapter 695C of NRS that does not restrict coverage for a preexisting condition may require an affiliation period before coverage becomes effective under a plan of insurance if the affiliation period applies uniformly to all employees or other persons insured and without regard to any health status-related factors. During the affiliation period, the carrier shall not collect any premiums for coverage of the employee or other insured.
4. An insurer that restricts coverage for preexisting conditions shall not impose an affiliation period.
5. A carrier shall not impose any exclusion for a preexisting condition:
(a) Relating to pregnancy.
(b) In the case of a person who, as of the last day of the 30-day period beginning on the date of the birth of the person, is covered under creditable coverage.
(c) In the case of a child who is adopted or placed for adoption before attaining the age of 18 years and who, as of the last day of the 30-day period beginning on the date of adoption or placement for adoption, whichever is earlier, is covered under creditable coverage. The provisions of this paragraph do not apply to coverage before the date of adoption or placement for adoption.
(d) In the case of a condition for which medical advice, diagnosis, care or treatment was recommended or received for the first time while the covered person held creditable coverage, and the medical advice, diagnosis, care or treatment was a benefit under the plan, if the creditable coverage was continuous to a date not more than 63 days before the effective date of the new coverage.
Ê The provisions of paragraphs (b) and (c) do not apply to a person after the end of the first 63-day period during all of which the person was not covered under any creditable coverage.
6. As used in this section, “late enrollee” means an eligible employee, or a dependent of the eligible employee, who requests enrollment in a group health plan following the initial period of enrollment, if that initial period of enrollment is at least 30 days, during which the person is entitled to enroll under the terms of the health benefit plan. The term does not include an eligible employee or a dependent of the eligible employee if:
(a) The employee or dependent:
(1) Was covered under creditable coverage at the time of the initial enrollment;
(2) Lost coverage under creditable coverage as a result of cessation of contributions by his or her employer, termination of employment or eligibility, reduction in the number of hours of employment, involuntary termination of creditable coverage, or death of, or divorce or legal separation from, a covered spouse; and
(3) Requests enrollment not later than 30 days after the date on which the creditable coverage of the employee or dependent was terminated or on which the change in conditions that gave rise to the termination of the coverage occurred.
(b) The employee enrolls during the open enrollment period, as provided in the contract or as otherwise specifically provided by specific statute.
(c) The employer of the employee offers several health benefit plans and the employee elected a different plan during an open enrollment period.
(d) A court has ordered coverage to be provided to the spouse or a minor or dependent child of an employee under a health benefit plan of the employee and a request for enrollment is made within 30 days after the issuance of the court order.
(e) The employee changes status from not being an eligible employee to being an eligible employee and requests enrollment, subject to any waiting period, within 30 days after the change in status.
(f) The person has continued coverage in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272, and that coverage has been exhausted.
(Added to NRS by 1997, 2904; A 1999, 2808; 2001, 2225)