31A-22-605.1 - Preexisting condition limitations.
31A-22-605.1. Preexisting condition limitations.
(1) Any provision dealing with preexisting conditions shall be consistent with thissection, Section 31A-22-609, and rules adopted by the commissioner.
(2) Except as provided in this section, an insurer that elects to use an application formwithout questions concerning the insured's health or medical treatment history shall providecoverage under the policy for any loss which occurs more than 12 months after the effective dateof coverage due to a preexisting condition which is not specifically excluded from coverage.
(3) (a) An insurer that issues a specified disease policy may not deny a claim for loss dueto a preexisting condition that occurs more than six months after the effective date of coverage.
(b) A specified disease policy may impose a preexisting condition exclusion only if theexclusion relates to a preexisting condition which first manifested itself within six months priorto the effective date of coverage or which was diagnosed by a physician at any time prior to theeffective date of coverage.
(4) (a) Except as provided in this Subsection (4), a health benefit plan may impose apreexisting condition exclusion only if:
(i) the exclusion relates to a preexisting condition for which medical advice, diagnosis,care, or treatment was recommended or received within the six-month period ending on theenrollment date from an individual licensed or similarly authorized to provide those servicesunder state law and operating within the scope of practice authorized by state law;
(ii) the exclusion period ends no later than 12 months after the enrollment date, or in thecase of a late enrollee, 18 months after the enrollment date; and
(iii) the exclusion period is reduced by the number of days of creditable coverage theenrollee has as of the enrollment date, in accordance with Subsection (4)(b).
(b) (i) The amount of creditable coverage allowed under Subsection (4)(a)(iii) isdetermined by counting all the days on which the individual has one or more types of creditablecoverage.
(ii) Days of creditable coverage that occur before a significant break in coverage are notrequired to be counted.
(A) Days in a waiting period or affiliation period are not taken into account indetermining whether a significant break in coverage has occurred.
(B) For an individual who elects federal COBRA continuation coverage during thesecond election period provided under the federal Trade Act of 2002, the days between the datethe individual lost group health plan coverage and the first day of the second COBRA electionperiod are not taken into account in determining whether a significant break in coverage hasoccurred.
(c) A group health benefit plan may not impose a preexisting condition exclusion relatingto pregnancy.
(d) (i) An insurer imposing a preexisting condition exclusion shall provide a writtengeneral notice of preexisting condition exclusion as part of any written application materials.
(ii) The general notice shall include:
(A) a description of the existence and terms of any preexisting condition exclusion underthe plan, including the six-month period ending on the enrollment date, the maximum preexistingcondition exclusion period, and how the insurer will reduce the maximum preexisting conditionexclusion period by creditable coverage;
(B) a description of the rights of individuals:
(I) to demonstrate creditable coverage, including any applicable waiting periods, througha certificate of creditable coverage or through other means; and
(II) to request a certificate of creditable coverage from a prior plan;
(C) a statement that the current plan will assist in obtaining a certificate of creditablecoverage from any prior plan or issuer if necessary; and
(D) a person to contact, and an address and telephone number for the person, forobtaining additional information or assistance regarding the preexisting condition exclusion.
(e) An insurer may not impose any limit on the amount of time that an individual has topresent a certificate or other evidence of creditable coverage.
(f) This Subsection (4) does not preclude application of any waiting period applicable toall new enrollees under the plan.
Enacted by Chapter 78, 2005 General Session