§ 3232 — Pre-existing condition provisions in health policies

§ 3232. Pre-existing condition provisions in health policies. Every\nindividual health insurance policy and every group or blanket accident\nand health insurance policy issued or issued for delivery in this state\nwhich includes a pre-existing condition provision shall contain in\nsubstance the following provision or provisions which in the opinion of\nthe superintendent are more favorable to the individuals, members of the\ngroup and their eligible dependents:\n (a) In determining whether a pre-existing condition provision applies\nto a covered person, the group or blanket accident and health insurance\npolicy or individual health insurance policy shall credit the time the\ncovered person was previously covered under creditable coverage, if the\nprevious creditable coverage was continuous to a date not more than\nsixty-three days prior to the enrollment date of the new coverage. In\nthe case of previous health maintenance organization coverage, any\naffiliation period prior to that previous coverage becoming effective\nshall also be credited pursuant to this subsection.\n (b) No pre-existing condition provision shall exclude coverage for a\nperiod in excess of twelve months following the enrollment date of\ncoverage for the covered person and may only relate to a condition\n(whether physical or mental), regardless of the cause of the condition,\nfor which medical advice, diagnosis, care or treatment was recommended\nor received within the six-month period ending on the enrollment date.\nFor purposes of this section "enrollment date" means the first day of\ncoverage of the individual under the policy or, if earlier, the first\nday of the waiting period that must pass with respect to an individual\nbefore such individual is eligible to be covered for benefits. If an\nindividual seeks and obtains coverage in the individual market, any\nperiod after the date the individual files a substantially complete\napplication for coverage and before the first day of coverage is a\nwaiting period. For purposes of this section genetic information shall\nnot be treated as a pre-existing condition in the absence of a diagnosis\nof the condition related to such information. No pre-existing condition\nlimitation provision shall exclude coverage in the case of:\n (1) an individual who, as of the last day of the thirty-day period\nbeginning with the date of birth, is covered under creditable coverage\nas defined in subsection (c) of this section;\n (2) a child who is adopted or placed for adoption before attaining\neighteen years of age and who, as of the last day of the thirty-day\nperiod beginning on the date of the adoption or placement for adoption,\nis covered under creditable coverage as defined in subsection (c) of\nthis section;\n (3) pregnancy (except in an individual health insurance policy or a\nstudent blanket accident and health insurance policy in which an insurer\nmay exclude coverage, subject to a credit for previous creditable\ncoverage, for a period not to exceed ten months for a pregnancy existing\non the enrollment date); or\n (4) an individual, and any dependent of such individual, who is\neligible for a federal tax credit under the federal Trade Adjustment\nAssistance Reform Act of 2002 and who has three months or more of\ncreditable coverage.\n Paragraphs one and two of this subsection shall no longer apply to an\nindividual after the end of the first sixty-three day period during all\nof which the individual was not covered under any creditable coverage.\n (c) For purposes of this section "creditable coverage" means, with\nrespect to an individual, coverage of the individual under any of the\nfollowing:\n (1) A group health plan;\n (2) Health insurance coverage;\n (3) Part A or B of title XVIII of the Social Security Act;\n (4) Title XIX of the Social Security Act, other than coverage\nconsisting solely of benefits under section 1928;\n (5) Chapter 55 of title 10, United States Code;\n (6) A medical care program of the Indian Health Service or of a tribal\norganization;\n (7) A state health benefits risk pool;\n (8) A health plan offered under chapter 89 of title 5, United States\nCode;\n (9) A public health plan (as defined in regulations);\n (10) A health benefit plan under section 5(e) of the Peace Corps Act\n(22 U.S.C. 2504(e)).\n (d)(1) For purposes of applying the credit of such creditable coverage\nan insurer shall count a period of creditable coverage without regard to\nthe specific benefits covered during the period.\n (2) Alternatively, an insurer may elect to count the period of\ncreditable coverage based on coverage of benefits within each of several\nclasses or categories of benefits as specified in regulations. Such\nelection shall be made on a uniform basis for all insureds, participants\nand beneficiaries. Pursuant to such election an insurer shall count the\nperiod of creditable coverage with respect to any class or category of\nbenefits if any level of benefits is covered within such class or\ncategory. An insurer making such election shall prominently state in any\ndisclosure statement, and shall set forth in any policy or certificate\nissued in connection with the coverage, that the insurer has made such\nelection. Such disclosure statement shall include a description of the\neffect of the election with regard to the application of creditable\ncoverage.\n (3) Notwithstanding the foregoing paragraph, for purposes of\ndetermining the extent to which a pre-existing condition limitation has\nbeen satisfied in a policy issued pursuant to subsection (l) of section\nthree thousand two hundred sixteen of this article within thirty days of\ndiscontinuance of a class of health maintenance organization direct\npayment contract for enrollees whose contract was discontinued, an\ninsurer shall credit the time that the enrollee was covered under a\nhealth maintenance organization direct payment contract issued prior to\nJanuary first, nineteen hundred ninety-six, without regard to the\nspecific benefits covered under the health maintenance organization\ncontract.\n (4) With respect to an "eligible individual", as defined in section\n2741(b) of the federal Public Health Service Act, 42 U.S.C. § 300\ngg-41(b), an insurer may not impose any pre-existing condition exclusion\nin an individual health insurance policy. For all other covered persons,\nthe pre-existing condition crediting requirement of subsection (a) of\nthis section shall be applicable.\n (e) For the purposes of this section the term "group health plan"\nmeans an employee welfare benefit plan (as defined in section 3(1) of\nthe Employee Retirement Income Security Act of 1974) to the extent that\nthe plan provides medical care (including items and services paid for as\nmedical care) to employees or their dependents (as defined under the\nterms of the plan) directly or through insurance, reimbursement or\notherwise.\n (f) An insurer shall not impose any pre-existing condition exclusion\nin an individual or group policy of hospital, medical, surgical or\nprescription drug expense insurance.\n