§ 27-18.6-3 - Limitation on preexisting condition exclusion.
SECTION 27-18.6-3
§ 27-18.6-3 Limitation on preexistingcondition exclusion. – (a) Notwithstanding any of the provisions of this title to the contrary, agroup health plan and a health insurance carrier offering group healthinsurance coverage shall not deny, exclude, or limit benefits with respect to aparticipant or beneficiary because of a preexisting condition exclusion exceptif:
(i) The exclusion relates to a condition (whether physical ormental), regardless of the cause of the condition, for which medical advice,diagnosis, care, or treatment was recommended or received within the six (6)month period ending on the enrollment date;
(ii) The exclusion extends for a period of not more thantwelve (12) months (or eighteen (18) months in the case of a late enrollee)after the enrollment date; and
(iii) The period of the preexisting condition exclusion isreduced by the aggregate of the periods of creditable coverage, if any,applicable to the participant or the beneficiary as of the enrollment date.
(2) For purposes of this section, genetic information shallnot be treated as a preexisting condition in the absence of a diagnosis of thecondition related to that information.
(b) With respect to paragraph (a)(1)(iii) of this section, aperiod of creditable coverage shall not be counted, with respect to enrollmentof an individual under a group health plan, if, after that period and beforethe enrollment date, there was a sixty-three (63) day period during which theindividual was not covered under any creditable coverage.
(c) Any period that an individual is in a waiting period forany coverage under a group health plan or for group health insurance or is inan affiliation period shall not be taken into account in determining thecontinuous period under subsection (b) of this section.
(d) Except as otherwise provided in subsection (e) of thissection, for purposes of applying paragraph (a)(1)(iii) of this section, agroup health plan and a health insurance carrier offering group healthinsurance coverage shall count a period of creditable coverage without regardto the specific benefits covered during the period.
(e) A group health plan or a health insurance carrieroffering group health insurance may elect to apply paragraph (a)(1)(iii) ofthis section based on coverage of benefits within each of several classes orcategories of benefits. Those classes or categories of benefits are to bedetermined by the secretary of the United States Department of Health and HumanServices pursuant to regulation. The election shall be made on a uniform basisfor all participants and beneficiaries. Under the election, a group health planor carrier shall count a period of creditable coverage with respect to anyclass or category of benefits if any level of benefits is covered within theclass or category.
(2) In the case of an election under this subsection withrespect to a group health plan (whether or not health insurance coverage isprovided in connection with that plan), the plan shall:
(i) Prominently state in any disclosure statements concerningthe plan, and state to each enrollee under the plan, that the plan has made theelection; and
(ii) Include in the statements a description of the effect ofthis election.
(3) In the case of an election under this subsection withrespect to health insurance coverage offered by a carrier in the large groupmarket, the carrier shall:
(i) Prominently state in any disclosure statements concerningthe coverage, and to each employer at the time of the offer or sale of thecoverage, that the carrier has made the election; and
(ii) Include in the statements a description of the effect ofthe election.
(f) A group health plan and a health insurance carrieroffering group health insurance coverage may not impose any preexistingcondition exclusion in the case of an individual who, as of the last day of thethirty (30) day period beginning with the date of birth, is covered undercreditable coverage.
(2) Subdivision (1) of this subsection shall no longer applyto an individual after the end of the first sixty-three (63) day period duringall of which the individual was not covered under any creditable coverage.Moreover, any period that an individual is in a waiting period for any coverageunder a group health plan (or for group health insurance coverage) or is in anaffiliation period shall not be taken into account in determining thecontinuous period for purposes of determining creditable coverage.
(g) A group health plan and a health insurance carrieroffering group health insurance coverage may not impose any preexistingcondition exclusion in the case of a child who is adopted or placed foradoption before attaining eighteen (18) years of age and who, as of the lastday of the thirty (30) day period beginning on the date of the adoption orplacement for adoption, is covered under creditable coverage. The previoussentence does not apply to coverage before the date of the adoption orplacement for adoption.
(2) Subdivision (1) of this subsection shall no longer applyto an individual after the end of the first sixty-three (63) day period duringall of which the individual was not covered under any creditable coverage. Anyperiod that an individual is in a waiting period for any coverage under a grouphealth plan (or for group health insurance coverage) or is in an affiliationperiod shall not be taken into account in determining the continuous period forpurposes of determining creditable coverage.
(h) A group health plan and a health insurance carrieroffering group health insurance coverage may not impose any preexistingcondition exclusion relating to pregnancy as a preexisting condition.
(i) Periods of creditable coverage with respect to anindividual shall be established through presentation of certifications. A grouphealth plan and a health insurance carrier offering group health insurancecoverage shall provide certifications:
(i) At the time an individual ceases to be covered under theplan or becomes covered under a COBRA continuation provision;
(ii) In the case of an individual becoming covered under acontinuation provision, at the time the individual ceases to be covered underthat provision; and
(iii) On the request of an individual made not later thantwenty-four (24) months after the date of cessation of the coverage describedin paragraph (i) or (ii) of this subdivision, whichever is later.
(2) The certification under this subsection may be provided,to the extent practicable, at a time consistent with notices required under anyapplicable COBRA continuation provision.
(3) The certification described in this subsection is awritten certification of:
(i) The period of creditable coverage of the individual underthe plan and the coverage (if any) under the COBRA continuation provision; and
(ii) The waiting period (if any)(and affiliation period, ifapplicable) imposed with respect to the individual for any coverage under theplan.
(4) To the extent that medical care under a group health planconsists of group health insurance coverage, the plan is deemed to havesatisfied the certification requirement under this subsection if the healthinsurance carrier offering the coverage provides for the certification inaccordance with this subsection.
(5) In the case of an election taken pursuant to subsection(e) of this section by a group health plan or a health insurance carrier, ifthe plan or carrier enrolls an individual for coverage under the plan and theindividual provides a certification of creditable coverage, upon request of theplan or carrier, the entity which issued the certification shall promptlydisclose to the requisition plan or carrier information on coverage of classesand categories of health benefits available under that entity's plan orcoverage, and the entity may charge the requesting plan or carrier for thereasonable cost of disclosing the information.
(6) Failure of an entity to provide information under thissubsection with respect to previous coverage of an individual so as toadversely affect any subsequent coverage of the individual under another grouphealth plan or health insurance coverage, as determined in accordance withrules and regulations established by the secretary of the United StatesDepartment of Health and Human Services, is a violation of this chapter.
(j) A group health plan and a health insurance carrieroffering group health insurance coverage in connection with a group health planshall permit an employee who is eligible, but not enrolled, for coverage underthe terms of the plan (or a dependent of an employee if the dependent iseligible, but not enrolled, for coverage under the terms) to enroll forcoverage under the terms of the plan if each of the following conditions aremet:
(1) The employee or dependent was covered under a grouphealth plan or had health insurance coverage at the time coverage waspreviously offered to the employee or dependent;
(2) The employee stated in writing at the time that coverageunder a group health plan or health insurance coverage was the reason fordeclining enrollment, but only if the plan sponsor or carrier (if applicable)required a statement at the time and provided the employee with notice of thatrequirement (and the consequences of the requirement) at the time;
(3) The employee's or dependent's coverage described insubsection (j)(1):
(i) Was under a COBRA continuation provision and the coverageunder that provision was exhausted; or
(ii) Was not under a continuation provision and either thecoverage was terminated as a result of loss of eligibility for the coverage(including as a result of legal separation, divorce, death, termination ofemployment, or reduction in the number of hours of employment) or employercontributions towards the coverage were terminated; and
(4) Under the terms of the plan, the employee requestsenrollment not later than thirty (30) days after the date of exhaustion ofcoverage described in paragraph (3)(i) of this subsection or termination ofcoverage or employer contribution described in paragraph (3)(ii) of thissubsection.
(k) If a group health plan makes coverage available withrespect to a dependent of an individual, the individual is a participant underthe plan (or has met any waiting period applicable to becoming a participantunder the plan and is eligible to be enrolled under the plan but for a failureto enroll during a previous enrollment period), and a person becomes adependent of the individual through marriage, birth, or adoption or placementthrough adoption, the group health plan shall provide for a dependent specialenrollment period during which the person (or, if not enrolled, the individual)may be enrolled under the plan as a dependent of the individual, and in thecase of the birth or adoption of a child, the spouse of the individual may beenrolled as a dependent of the individual if the spouse is eligible forcoverage.
(2) A dependent special enrollment period shall be a periodof not less than thirty (30) days and shall begin on the later of:
(i) The date dependent coverage is made available; or
(ii) The date of the marriage, birth, or adoption orplacement for adoption (as the case may be).
(3) If an individual seeks to enroll a dependent during thefirst thirty (30) days of a dependent special enrollment period, the coverageof the dependent shall become effective:
(i) In the case of marriage, not later than the first day ofthe first month beginning after the date the completed request for enrollmentis received;
(ii) In the case of a dependent's birth, as of the date ofthe birth; or
(iii) In the case of a dependent's adoption or placement foradoption, the date of the adoption or placement for adoption.
(l) A health maintenance organization which offers healthinsurance coverage in connection with a group health plan and which does notimpose any preexisting condition exclusion allowed under subsection (a) of thissection with respect to any particular coverage option may impose anaffiliation period for the coverage option, but only if that period is applieduniformly without regard to any health status-related factors, and the perioddoes not exceed two (2) months (or three (3) months in the case of a lateenrollee).
(2) For the purposes of this subsection, an affiliation shallbegin on the enrollment date.
(3) An affiliation period under a plan shall run concurrentlywith any waiting period under the plan.
(4) The director may approve alternative methods from thosedescribed under this subsection to address adverse selection.
(m) For the purpose of determining creditable coveragepursuant to this chapter, no period before July 1, 1996, shall be taken intoaccount. Individuals who need to establish creditable coverage for periodsbefore July 1, 1996, and who would have the coverage credited but for theprohibition in the preceding sentence may be given credit for creditablecoverage for those periods through the presentation of documents or other meansin accordance with any rule or regulation that may be established by thesecretary of the United States Department of Health and Human Services.
(n) In the case of an individual who seeks to establishcreditable coverage for any period for which certification is not requiredbecause it relates to an event occurring before June 30, 1996, the individualmay present other credible evidence of coverage in order to establish theperiod of creditable coverage. The group health plan and a health insurancecarrier shall not be subject to any penalty or enforcement action with respectto the plan's or carrier's crediting (or not crediting) the coverage if theplan or carrier has sought to comply in good faith with the applicablerequirements of this section.