| (14) In determining whether a preexisting condition
provision applies to an individual covered by a small employer health
benefit plan, the small employer carrier must credit the time the
individual was covered under creditable coverage if the previous coverage
was in effect at any time during the 12 months preceding the effective
date of coverage under a small employer health benefit plan. Any waiting
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. Individual B's
coverage became effective on September 1, 2016. Under this example,
since there was a significant break in coverage, to determine the
length of creditable coverage, the small 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 small employer
health benefit plan. Individual B has creditable coverage of six months
and the issuer of the small employer health benefit plan may impose
a preexisting condition limitation for six months on Individual B.
(15) A small employer may establish a waiting period
in accordance with Insurance Code §1501.156. On completion of
the waiting period and enrollment within the time frame allowed by
§26.7(h) of this title (relating to Requirement to Insure Entire
Groups), coverage must be effective no later than the next premium
due date. Coverage may be effective at an earlier date as agreed between
the small employer and the small employer carrier.
(16) An HMO may impose an affiliation period in accordance
with Insurance Code §1501.104, if the period is applied uniformly
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.
(17) The imposition of an affiliation period by an
HMO does not preclude application of any applicable waiting period
as determined by the employer for all new entrants under a health
benefit plan.
(18) An affiliation period provision in a small employer
health benefit plan does not apply to an individual who would not
be subject to a preexisting condition limitation in accordance with
paragraphs (12) and (13) of this subsection.
(b) To determine if preexisting conditions exist, a
small employer carrier must ascertain the source of previous or existing
coverage of each eligible employee or dependent at the time the employee
or dependent initially enrolls into the health benefit plan provided
by the small employer carrier. The small employer carrier has the
responsibility to contact the source of the previous or existing coverage
to resolve any questions about the benefits or limitations related
to that coverage in the absence of a creditable coverage certification
form.
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| Source Note: The provisions of this §26.9 adopted to be effective December 30, 1993, 18 TexReg 9375; amended to be effective April 9, 1996, 21 TexReg 2648; amended to be effective March 5, 1998, 23 TexReg 2297; amended to be effective April 6, 2005, 30 TexReg 1931; amended to be effective May 17, 2017, 42 TexReg 2539 |
