| (a) A large employer carrier may not exclude any eligible
employee who meets the participation criteria or an eligible dependent,
if dependent coverage is offered to enrollees under a large employer
health benefit plan (including a late enrollee, who would otherwise
be covered under a large employer's health benefit plan), except to
the extent permitted under Insurance Code §§1501.102 - 1501.106
(concerning Preexisting Condition Provision; Treatment of Certain
Conditions as Preexisting Prohibited; Affiliation Period; Waiting
Period Permitted; and Certain Limitations or Exclusions of Coverage
Prohibited) and 1501.601 - 1501.609 (concerning Participation Criteria;
Coverage Requirements; Exclusion of Eligible Employee or Dependent
Prohibited; Declining Coverage; Minimum Contribution or Participation
Requirements; Employee Enrollment; Waiting Period; Coverage for Newborn
Children; Coverage for Adopted Children; and Coverage for Unmarried
Children).
(b) A preexisting condition provision in a large employer
health benefit plan may not apply to expenses incurred on or after
the expiration of the 12 months following the effective date of coverage
of the enrollee or late enrollee, except as authorized by subsection
(h)(2) of this section.
(c) A preexisting condition provision in a large employer
health benefit plan may not apply to coverage for a disease or condition
other than a disease or condition for which medical advice, diagnosis,
care, or treatment was recommended or received from an individual
licensed to provide those services under state law and operating within
the scope of practice authorized by state law during the six months
before the effective date of coverage.
(d) A large employer carrier may not treat genetic
information as a preexisting condition described by Insurance Code
§1501.102 in the absence of a diagnosis of the condition related
to the information.
(e) A large employer carrier may not treat a pregnancy
as a preexisting condition described by Insurance Code §1501.102.
(f) A preexisting condition provision in a large employer
health benefit plan may not apply to an individual who was continuously
covered for an aggregate period of 12 months under creditable coverage
that was in effect up to a date not more than 63 days before the effective
date of coverage under the large employer health benefit plan, excluding
any waiting or affiliation period. For example, Individual A has coverage
under an individual policy for six months beginning on May 1, 2014,
through October 31, 2014, followed by a gap in coverage of 61 days
until December 31, 2014. Individual A is covered under an individual
health plan beginning on January 1, 2015, for six months through June
30, 2015, followed by a gap in coverage of 62 days until August 31,
2015. The effective date of Individual A's coverage under a large
employer health benefit plan is September 1, 2015. Individual A has
12 months of creditable coverage and would not be subject to a preexisting
condition exclusion under the large employer health benefit plan.
(g) In determining whether a preexisting condition
provision applies to an individual covered by a large employer benefit
plan, the large employer carrier must credit the time the individual
was covered under previous creditable coverage if the previous coverage
was in effect at any time during the 12 months preceding the effective
date of coverage under a large employer health benefit plan. If the
previous coverage was issued under a health benefit plan, any waiting
or affiliation period that applied before that coverage became effective
also must be credited against the preexisting condition provision
period. For instance, Individual B is covered under an individual
health insurance policy for 18 months beginning May 1, 2014, through
November 30, 2015, followed by a four-month gap in coverage from December
1, 2015, to March 31, 2016. On April 1, 2016, Individual B is covered
under a group health plan for three months through June 30, 2016,
followed by a two-month gap in coverage until August 31, 2016. The
effective date of Individual B's coverage under a large employer health
insurance policy is September 1, 2016. Under this example, since there
was a significant break in coverage, to determine the length of creditable
coverage, the large employer carrier counts the creditable coverage
the individual had for the 12-month period preceding the effective
date of the individual's coverage under the large employer plan. Individual
B has creditable coverage of six months and the issuer of the large
employer health benefit plan may impose a preexisting condition limitation
for six months on Individual B.
(h) A large employer carrier must choose one of the
methods set forth in paragraph (1) or (2) of this subsection for handling
requests for enrollment from a late applicant in any health benefit
plan subject to this subchapter. The large employer carrier must use
the same method in regard to all health benefit plans.
(1) The employee or dependent may be excluded from
coverage and any application for coverage rejected until the next
annual open enrollment period and, on enrollment, may be subject to
a 12-month preexisting condition provision or, in the case of an HMO,
may be subject to a 60-day affiliation provision, as described by
Insurance Code §§1501.102 - 1501.104.
(2) The employee or dependent's application may be
accepted immediately and the employee or dependent enrolled as a late
enrollee during the plan year, in which case the preexisting condition
provision imposed for a late enrollee may not exceed 18 months or,
in the case of an HMO, the affiliation period may not exceed 90 days,
from the date of the late enrollee's application for coverage.
(3) The provisions of paragraphs (1) and (2) of this
subsection do not apply to employees or dependents under the special
circumstances listed as exceptions under the definition of late enrollee
in §26.4 of this title (relating to Definitions).
(4) Examples for applying subparagraphs (A) and (B)
of this paragraph, in the case of both insurers and HMOs: Individual
A requests coverage on October 1, 2014, after the enrollment period
of July 1, 2014, through July 31, 2014, has ended. The next annual
open enrollment period is July 1, 2015, through July 31, 2015. The
effective date of coverage for persons enrolling during an open enrollment
period is the beginning of the plan year, which is September 1 of
each year.
(A) If the carrier is an insurer and has elected to
exclude all applicants requesting late enrollment under health benefit
plans subject to this subchapter until the next open enrollment period,
Individual A must reapply for coverage in July 2015, and the carrier
may apply up to a 12-month preexisting condition period from the effective
date of coverage and, as with any other enrollee, the preexisting
condition period would begin on September 1, 2015, and expire on September
1, 2016.
(B) If the carrier is an insurer and has elected to
immediately accept applications for late enrollment under health benefit
plans subject to this subchapter and enroll the applicant during the
plan year, the carrier may apply up to an 18-month preexisting condition
period from the date of application. If Individual A applied for coverage
on October 1, 2014, the preexisting condition period would begin on
that date and would expire on April 1, 2016.
(C) If the carrier is an HMO and has elected to exclude
all applicants requesting late enrollment under health benefit plans
subject to this subchapter until the next open enrollment period,
Individual A must reapply for coverage in July 2015, and the carrier
may apply up to a 60-day affiliation period, as with any other enrollee.
(D) If the carrier is an HMO and has elected to immediately
accept applications for late enrollment under health benefit plans
subject to this subchapter and enroll the applicant during the plan
year, the carrier may apply up to a 90-day affiliation period from
the day Individual A applied for coverage.
(i) An HMO may impose an affiliation period if the
period is applied uniformly to each enrollee without regard to any
health-status-related factor. The affiliation period may not exceed
two months for an enrollee, other than a late enrollee, and may not
exceed 90 days for a late enrollee. An affiliation period under a
plan must run concurrently with any applicable waiting period under
the plan. An HMO may not impose any preexisting condition limitation,
except for an affiliation period.
(j) A large employer may establish a waiting period
under Insurance Code §1501.606(b) applicable to all new entrants
under the health benefit plan during which a new employee is not eligible
for coverage. The large employer must determine the duration of the
waiting period. A large employer carrier may not apply a waiting period
or other similar limitation of coverage (other than an exclusion for
preexisting medical conditions or an affiliation period consistent
with Insurance Code §§1501.102 - 1501.106 and 1501.601 -
1501.609, with respect to a new entrant, that is longer than the waiting
period established by the large employer for all other employees.
On completion of the waiting period and enrollment within the time
frame allowed by §26.305(a) of this title (relating to Cont'd... |
