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This entry was published on 2019-04-19
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SECTION 3232
Pre-existing condition provisions in health policies
Insurance (ISC) CHAPTER 28, ARTICLE 32
§ 3232. Pre-existing condition provisions in health policies. Every
individual health insurance policy and every group or blanket accident
and health insurance policy issued or issued for delivery in this state
which includes a pre-existing condition provision shall contain in
substance the following provision or provisions which in the opinion of
the superintendent are more favorable to the individuals, members of the
group and their eligible dependents:

(a) In determining whether a pre-existing condition provision applies
to a covered person, the group or blanket accident and health insurance
policy or individual health insurance policy shall credit the time the
covered person was previously covered under creditable coverage, if the
previous creditable coverage was continuous to a date not more than
sixty-three days prior to the enrollment date of the new coverage. In
the case of previous health maintenance organization coverage, any
affiliation period prior to that previous coverage becoming effective
shall also be credited pursuant to this subsection.

(b) No pre-existing condition provision shall exclude coverage for a
period in excess of twelve months following the enrollment date of
coverage for the covered person and may only relate to a condition
(whether physical or mental), regardless of the cause of the condition,
for which medical advice, diagnosis, care or treatment was recommended
or received within the six-month period ending on the enrollment date.
For purposes of this section "enrollment date" means the first day of
coverage of the individual under the policy or, if earlier, the first
day of the waiting period that must pass with respect to an individual
before such individual is eligible to be covered for benefits. If an
individual seeks and obtains coverage in the individual market, any
period after the date the individual files a substantially complete
application for coverage and before the first day of coverage is a
waiting period. For purposes of this section genetic information shall
not be treated as a pre-existing condition in the absence of a diagnosis
of the condition related to such information. No pre-existing condition
limitation provision shall exclude coverage in the case of:

(1) an individual who, as of the last day of the thirty-day period
beginning with the date of birth, is covered under creditable coverage
as defined in subsection (c) of this section;

(2) a child who is adopted or placed for adoption before attaining
eighteen years of age and who, as of the last day of the thirty-day
period beginning on the date of the adoption or placement for adoption,
is covered under creditable coverage as defined in subsection (c) of
this section;

(3) pregnancy (except in an individual health insurance policy or a
student blanket accident and health insurance policy in which an insurer
may exclude coverage, subject to a credit for previous creditable
coverage, for a period not to exceed ten months for a pregnancy existing
on the enrollment date); or

(4) an individual, and any dependent of such individual, who is
eligible for a federal tax credit under the federal Trade Adjustment
Assistance Reform Act of 2002 and who has three months or more of
creditable coverage.

Paragraphs one and two of this subsection shall no longer apply to an
individual after the end of the first sixty-three day period during all
of which the individual was not covered under any creditable coverage.

(c) For purposes of this section "creditable coverage" means, with
respect to an individual, coverage of the individual under any of the
following:

(1) A group health plan;

(2) Health insurance coverage;

(3) Part A or B of title XVIII of the Social Security Act;

(4) Title XIX of the Social Security Act, other than coverage
consisting solely of benefits under section 1928;

(5) Chapter 55 of title 10, United States Code;

(6) A medical care program of the Indian Health Service or of a tribal
organization;

(7) A state health benefits risk pool;

(8) A health plan offered under chapter 89 of title 5, United States
Code;

(9) A public health plan (as defined in regulations);

(10) A health benefit plan under section 5(e) of the Peace Corps Act
(22 U.S.C. 2504(e)).

(d)(1) For purposes of applying the credit of such creditable coverage
an insurer shall count a period of creditable coverage without regard to
the specific benefits covered during the period.

(2) Alternatively, an insurer may elect to count the period of
creditable coverage based on coverage of benefits within each of several
classes or categories of benefits as specified in regulations. Such
election shall be made on a uniform basis for all insureds, participants
and beneficiaries. Pursuant to such election an insurer shall count the
period of creditable coverage with respect to any class or category of
benefits if any level of benefits is covered within such class or
category. An insurer making such election shall prominently state in any
disclosure statement, and shall set forth in any policy or certificate
issued in connection with the coverage, that the insurer has made such
election. Such disclosure statement shall include a description of the
effect of the election with regard to the application of creditable
coverage.

(3) Notwithstanding the foregoing paragraph, for purposes of
determining the extent to which a pre-existing condition limitation has
been satisfied in a policy issued pursuant to subsection (l) of section
three thousand two hundred sixteen of this article within thirty days of
discontinuance of a class of health maintenance organization direct
payment contract for enrollees whose contract was discontinued, an
insurer shall credit the time that the enrollee was covered under a
health maintenance organization direct payment contract issued prior to
January first, nineteen hundred ninety-six, without regard to the
specific benefits covered under the health maintenance organization
contract.

(4) With respect to an "eligible individual", as defined in section
2741(b) of the federal Public Health Service Act, 42 U.S.C. § 300
gg-41(b), an insurer may not impose any pre-existing condition exclusion
in an individual health insurance policy. For all other covered persons,
the pre-existing condition crediting requirement of subsection (a) of
this section shall be applicable.

(e) For the purposes of this section the term "group health plan"
means an employee welfare benefit plan (as defined in section 3(1) of
the Employee Retirement Income Security Act of 1974) to the extent that
the plan provides medical care (including items and services paid for as
medical care) to employees or their dependents (as defined under the
terms of the plan) directly or through insurance, reimbursement or
otherwise.

(f) An insurer shall not impose any pre-existing condition exclusion
in an individual or group policy of hospital, medical, surgical or
prescription drug expense insurance.