§1062. Increased portability through limitation on preexisting condition exclusions
A. Limitation on preexisting condition exclusion period; crediting for periods of
previous coverage. Subject to the provisions of Subsection D of this Section, a group health
plan, and a health insurance issuer offering group health insurance coverage, may, with
respect to a participant or beneficiary, impose a preexisting condition exclusion only if:
(1)Such exclusion relates 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.
(2)Such exclusion extends for a period of not more than twelve months, or eighteen
months in the case of
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§1062. Increased portability through limitation on preexisting condition exclusions
A. Limitation on preexisting condition exclusion period; crediting for periods of
previous coverage. Subject to the provisions of Subsection D of this Section, a group health
plan, and a health insurance issuer offering group health insurance coverage, may, with
respect to a participant or beneficiary, impose a preexisting condition exclusion only if:
(1) Such exclusion relates 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.
(2) Such exclusion extends for a period of not more than twelve months, or eighteen
months in the case of a late enrollee, after the enrollment date.
(3) The period of any such preexisting condition exclusion is reduced by the
aggregate of the periods of creditable coverage, if any, as defined in R.S. 22:1061(4)
applicable to the participant or beneficiary as of the enrollment date.
B.(1) A period of creditable coverage shall not be counted, with respect to
enrollment of an individual under a group health plan, if, after such period and before the
enrollment date, there was a sixty-three day period during all of which the individual was not
covered under any creditable coverage.
(2) For purposes of Paragraph (1) of this Subsection and Paragraph (D)(4) of this
Section, any period that an individual is in a waiting period for any coverage under a group
health plan, or for group health insurance coverage, or is in an affiliation period, shall not be
taken into account in determining the continuous period.
(3)(a) Except as otherwise provided under Paragraph (2) of this Subsection, a group
health plan, and a health insurance issuer offering group health insurance coverage, shall
count a period of creditable coverage without regard to the specific benefits covered during
the period.
(b) A group health plan, or a health insurance issuer offering group health insurance,
may elect to count a period of creditable coverage based on coverage of benefits within each
of several classes or categories of benefits specified in regulations promulgated by the
commissioner. Such election shall be made on a uniform basis for all participants and
beneficiaries. Under such election a group health plan or issuer shall count a 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.
(c) In the case of an election with respect to a group health plan under Subparagraph
(b) of this Paragraph, whether or not health insurance coverage is provided in connection
with such plan, the plan shall:
(i) Prominently state in any disclosure statements concerning the plan, and state to
each enrollee at the time of enrollment under the plan, that the plan has made such election.
(ii) Include in such statements a description of the effect of this election.
(d) In the case of an election under Subparagraph (b) of this Paragraph with respect
to health insurance coverage offered by an issuer in the small or large group market, the
issuer:
(i) Shall prominently state in any disclosure statements concerning the coverage, and
to each employer at the time of the offer or sale of the coverage, that the issuer has made
such election.
(ii) Shall include in such statements a description of the effect of such election.
(4) Periods of creditable coverage with respect to an individual shall be established
through presentation of certifications described in Subsection E of this Section or in such
other manner as may be specified in regulations.
C. Except as provided in Paragraph (4) of this Subsection, a group health plan and
a health insurance issuer offering group health insurance coverage may not impose any
preexisting condition exclusion:
(1) In the case of an individual who, as of the last day of the thirty-day period
beginning with the date of birth, is covered under creditable coverage.
(2) In the case of 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. This
Paragraph shall not apply to coverage before the date of such adoption or placement for
adoption.
(3) Relating to pregnancy as a preexisting condition.
(4) Paragraphs (1) and (2) of this Subsection shall not 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.
D.(1) A group health plan, and a health insurance issuer offering group health
insurance coverage, shall send the certification of the period of creditable coverage no more
than twenty days after such certification is requested by an individual who ceases to be
covered under the issuer's policy or plan.
(2) The certification shall include a written certification of the following:
(a) The period of creditable coverage of the individual under such plan and the
coverage, if any, under such COBRA continuation provision.
(b) The waiting period, if any, and affiliation period if applicable, imposed with
respect to the individual for any coverage under such plan.
(3) To the extent that medical care under a group health plan consists of group health
insurance coverage, the plan is deemed to have satisfied the certification requirement under
Paragraphs (1) and (2) of this Subsection if the health insurance issuer offering the coverage
provides for such certification in accordance therewith.
(4) A plan or issuer providing certification of coverage of an individual pursuant to
an election under Subparagraph (B)(3)(b):
(a) Upon request of the succeeding plan or issuer, shall promptly disclose to such
requesting plan or issuer information on coverage of classes and categories of health benefits
available under such entity's plan or coverage.
(b) May charge the requesting plan or issuer for the reasonable cost of disclosing
such information.
(5) The commissioner of insurance shall take all appropriate measures to prevent an
entity's failure to provide information under this Subsection with respect to previous
coverage of an individual from adversely affecting any subsequent coverage of the individual
under another group health plan or health insurance coverage. Such measures shall include
enforcement of all applicable state and federal laws and regulations and adoption of any
reasonable regulations required for the enforcement thereof.
E.(1) A group health plan, and a health insurance issuer offering group health
insurance coverage in connection with a group health plan, shall permit an employee who
is eligible, but not enrolled, for coverage under the terms of the plan, or a dependent of such
an employee if the dependent is eligible, but not enrolled, for coverage under such terms, to
enroll for coverage under the terms of the plan if each of the following conditions are met:
(a) The employee or dependent was covered under a group health plan or had health
insurance coverage at the time coverage was previously offered to the employee or
dependent.
(b) The employee stated in writing at such time that coverage under a group health
plan or health insurance coverage was the reason for declining enrollment, but only if the
plan sponsor or issuer, if applicable, required such a statement at such time and provided the
employee with notice of such requirement, and the consequences of such requirement, at
such time.
(c) The employee's or dependent's coverage described in Subparagraph (a) of this
Paragraph.
(i) Was under a COBRA continuation provision and the coverage under such
provision was exhausted.
(ii) Was not under such a provision and either the coverage was terminated as a
result of loss of eligibility for the coverage, including as a result of legal separation, divorce,
death, termination of employment, or reduction in the number of hours of employment, or
employer contributions towards such coverage were terminated.
(d) Under the terms of the plan, the employee requests such enrollment not later than
thirty days after the date of exhaustion of coverage described in Item (c)(i) of this Paragraph
or termination of coverage or employer contribution described in Item (c)(ii) of this
Paragraph.
(2)(a) Subject to eligibility requirements of group coverage pursuant to state law, a
group health plan shall provide for a dependent special enrollment period during which the
person, or, if not otherwise enrolled, the individual, may be enrolled under the plan as a
dependent of the individual, if:
(i) A group health plan makes coverage available with respect to a dependent of an
individual.
(ii) The individual is a participant under the plan, or has met any waiting period
applicable to becoming a participant under the plan and is eligible to be enrolled under the
plan but for a failure to enroll during a previous enrollment period.
(iii) A person becomes such a dependent of the individual through marriage, birth,
or adoption or placement for adoption. In the case of the birth or adoption of a child, the
spouse of the individual may be enrolled as a dependent of the individual if such spouse is
otherwise eligible for coverage.
(iv) The dependent child was enrolled in the Louisiana Children's Health Insurance
Program or a Medicaid program prior to requesting enrollment in the group health plan, but
is no longer eligible to be covered under either the Louisiana Children's Health Insurance
Program or a Medicaid program.
(b) A dependent special enrollment period under this Paragraph shall be a period of
not less than thirty days and shall begin on:
(i) In the case of marriage, adoption, or placement for adoption, the later of the
following: the date dependent coverage is made available or the date of the marriage,
adoption, or placement for adoption of a child, as the case may be.
(ii) In the case of a dependent child losing eligibility for coverage by the Louisiana
Children's Health Insurance Program or a Medicaid program, the later of the following: the
date dependent coverage is made available or the date when coverage under the Louisiana
Children's Health Insurance Program or a Medicaid program ceases.
(c) If an individual seeks to enroll a dependent during the first thirty days of such a
dependent special enrollment period, the coverage of the dependent shall become effective
as follows:
(i) In the case of marriage, not later than the first day of the first month beginning
after the date the completed request for enrollment is received.
(ii) In the case of a dependent's adoption or placement for adoption, the date of such
adoption or placement for adoption.
(iii) In the case of a dependent losing eligibility for coverage by the Louisiana
Children's Health Insurance Program or a Medicaid program, the date when such coverage
ceases.
F.(1) A health maintenance organization which offers health insurance coverage in
connection with a group health plan and which does not impose any preexisting condition
exclusion allowed under Subsection A of this Section with respect to any particular coverage
option may impose an affiliation period for such coverage option, but only if the following
apply:
(a) Such period is applied uniformly without regard to any health status-related
factors.
(b) Such period does not exceed two months or three months in the case of a late
enrollee.
(2) An affiliation period shall begin on the enrollment date and shall run concurrently
with any waiting period under the plan.
(3) A health maintenance organization may use alternative methods to address
adverse selection following approval by the commissioner.
NOTE: Former R.S. 22:1062 redesignated as R.S. 22:842 by Acts 2008, No.
415, §1, eff. Jan. 1, 2009.