29 U.S.C. § 1181 : US Code - Section 1181: Increased portability through limitation on preexisting condition exclusions

Search 29 U.S.C. § 1181 : US Code - Section 1181: Increased portability through limitation on preexisting condition exclusions

(a) Limitation on preexisting condition exclusion period; crediting
for periods of previous coverage
Subject to 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 6-month period ending on the enrollment date;
(2) such exclusion extends for a period of not more than 12
months (or 18 months in the case of a late enrollee) after the
enrollment date; and
(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 subsection (c)(1) of this section)
applicable to the participant or beneficiary as of the enrollment
date.
(b) Definitions
For purposes of this part -
(1) Preexisting condition exclusion
(A) In general
The term "preexisting condition exclusion" means, with
respect to coverage, a limitation or exclusion of benefits
relating to a condition based on the fact that the condition
was present before the date of enrollment for such coverage,
whether or not any medical advice, diagnosis, care, or
treatment was recommended or received before such date.
(B) Treatment of genetic information
Genetic information shall not be treated as a condition
described in subsection (a)(1) of this section in the absence
of a diagnosis of the condition related to such information.
(2) Enrollment date
The term "enrollment date" means, with respect to an individual
covered under a group health plan or health insurance coverage,
the date of enrollment of the individual in the plan or coverage
or, if earlier, the first day of the waiting period for such
enrollment.
(3) Late enrollee
The term "late enrollee" means, with respect to coverage under
a group health plan, a participant or beneficiary who enrolls
under the plan other than during -
(A) the first period in which the individual is eligible to
enroll under the plan, or
(B) a special enrollment period under subsection (f) of this
section.
(4) Waiting period
The term "waiting period" means, with respect to a group health
plan and an individual who is a potential participant or
beneficiary in the plan, the period that must pass with respect
to the individual before the individual is eligible to be covered
for benefits under the terms of the plan.
(c) Rules relating to crediting previous coverage
(1) "Creditable coverage" defined
For purposes of this part, the term "creditable coverage"
means, with respect to an individual, coverage of the individual
under any of the following:
(A) A group health plan.
(B) Health insurance coverage.
(C) Part A or part B of title XVIII of the Social Security
Act [42 U.S.C. 1395c et seq.; 1395j et seq.].
(D) Title XIX of the Social Security Act [42 U.S.C. 1396 et
seq.], other than coverage consisting solely of benefits under
section 1928 [42 U.S.C. 1396s].
(E) Chapter 55 of title 10.
(F) A medical care program of the Indian Health Service or of
a tribal organization.
(G) A State health benefits risk pool.
(H) A health plan offered under chapter 89 of title 5.
(I) A public health plan (as defined in regulations).
(J) A health benefit plan under section 2504(e) of title 22.
Such term does not include coverage consisting solely of coverage
of excepted benefits (as defined in section 1191b(c) of this
title).
(2) Not counting periods before significant breaks in coverage
(A) In general
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 63-day period during all of which the individual
was not covered under any creditable coverage.
(B) Waiting period not treated as a break in coverage
For purposes of subparagraph (A) and subsection (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 (as
defined in subsection (g)(2) of this section) shall not be
taken into account in determining the continuous period under
subparagraph (A).
(3) Method of crediting coverage
(A) Standard method
Except as otherwise provided under subparagraph (B), for
purposes of applying subsection (a)(3) of this section, 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) Election of alternative method
A group health plan, or a health insurance issuer offering
group health insurance coverage, may elect to apply subsection
(a)(3) of this section based on coverage of benefits within
each of several classes or categories of benefits specified in
regulations rather than as provided under subparagraph (A).
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) Plan notice
In the case of an election with respect to a group health
plan under subparagraph (B) (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, and
(ii) include in such statements a description of the effect
of this election.
(4) Establishment of period
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.
(d) Exceptions
(1) Exclusion not applicable to certain newborns
Subject to paragraph (4), a group health plan, and a health
insurance issuer offering group health insurance coverage, may
not impose any preexisting condition exclusion in the case of an
individual who, as of the last day of the 30-day period beginning
with the date of birth, is covered under creditable coverage.
(2) Exclusion not applicable to certain adopted children
Subject to paragraph (4), a group health plan, and a health
insurance issuer offering group health insurance coverage, may
not impose any preexisting condition exclusion in the case of a
child who is adopted or placed for adoption before attaining 18
years of age and who, as of the last day of the 30-day period
beginning on the date of the adoption or placement for adoption,
is covered under creditable coverage. The previous sentence shall
not apply to coverage before the date of such adoption or
placement for adoption.
(3) Exclusion not applicable to pregnancy
A group health plan, and health insurance issuer offering group
health insurance coverage, may not impose any preexisting
condition exclusion relating to pregnancy as a preexisting
condition.
(4) Loss if break in coverage
Paragraphs (1) and (2) shall no longer apply to an individual
after the end of the first 63-day period during all of which the
individual was not covered under any creditable coverage.
(e) Certifications and disclosure of coverage
(1) Requirement for certification of period of creditable
coverage
(A) In general
A group health plan, and a health insurance issuer offering
group health insurance coverage, shall provide the
certification described in subparagraph (B) -
(i) at the time an individual ceases to be covered under
the plan or otherwise becomes covered under a COBRA
continuation provision,
(ii) in the case of an individual becoming covered under
such a provision, at the time the individual ceases to be
covered under such provision, and
(iii) on the request on behalf of an individual made not
later than 24 months after the date of cessation of the
coverage described in clause (i) or (ii), whichever is later.
The certification under clause (i) may be provided, to the
extent practicable, at a time consistent with notices required
under any applicable COBRA continuation provision.
(B) Certification
The certification described in this subparagraph is a written
certification of -
(i) the period of creditable coverage of the individual
under such plan and the coverage (if any) under such COBRA
continuation provision, and
(ii) the waiting period (if any) (and affiliation period,
if applicable) imposed with respect to the individual for any
coverage under such plan.
(C) Issuer compliance
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 this
paragraph if the health insurance issuer offering the coverage
provides for such certification in accordance with this
paragraph.
(2) Disclosure of information on previous benefits
In the case of an election described in subsection (c)(3)(B) of
this section by a group health plan or health insurance issuer,
if the plan or issuer enrolls an individual for coverage under
the plan and the individual provides a certification of coverage
of the individual under paragraph (1) -
(A) upon request of such plan or issuer, the entity which
issued the certification provided by the individual 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, and
(B) such entity may charge the requesting plan or issuer for
the reasonable cost of disclosing such information.
(3) Regulations
The Secretary shall establish rules to prevent an entity's
failure to provide information under paragraph (1) or (2) 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.
(f) Special enrollment periods
(1) Individuals losing other coverage
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 is 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) -
(i) was under a COBRA continuation provision and the
coverage under such provision was exhausted; or
(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 toward such
coverage were terminated.
(D) Under the terms of the plan, the employee requests such
enrollment not later than 30 days after the date of exhaustion
of coverage described in subparagraph (C)(i) or termination of
coverage or employer contribution described in subparagraph
(C)(ii).
(2) For dependent beneficiaries
(A) In general
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), and
(iii) a person becomes such a dependent of the individual
through marriage, birth, or adoption or placement for
adoption,
the group health plan shall provide for a dependent special
enrollment period described in subparagraph (B) during which
the person (or, if not otherwise enrolled, the individual) may
be enrolled under the plan as a dependent of the individual,
and 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.
(B) Dependent special enrollment period
A dependent special enrollment period under this subparagraph
shall be a period of not less than 30 days and shall begin on
the later of -
(i) the date dependent coverage is made available, or
(ii) the date of the marriage, birth, or adoption or
placement for adoption (as the case may be) described in
subparagraph (A)(iii).
(C) No waiting period
If an individual seeks to enroll a dependent during the first
30 days of such a dependent special enrollment period, the
coverage of the dependent shall become effective -
(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 birth, as of the date of
such birth; or
(iii) in the case of a dependent's adoption or placement
for adoption, the date of such adoption or placement for
adoption.
(g) Use of affiliation period by HMOs as alternative to preexisting
condition exclusion
(1) In general
In the case of a group health plan that offers medical care
through health insurance coverage offered by a health maintenance
organization, the plan may provide for an affiliation period with
respect to coverage through the organization only if -
(A) no preexisting condition exclusion is imposed with
respect to coverage through the organization,
(B) the period is applied uniformly without regard to any
health status-related factors, and
(C) such period does not exceed 2 months (or 3 months in the
case of a late enrollee).
(2) Affiliation period
(A) Defined
For purposes of this part, the term "affiliation period"
means a period which, under the terms of the health insurance
coverage offered by the health maintenance organization, must
expire before the health insurance coverage becomes effective.
The organization is not required to provide health care
services or benefits during such period and no premium shall be
charged to the participant or beneficiary for any coverage
during the period.
(B) Beginning
Such period shall begin on the enrollment date.
(C) Runs concurrently with waiting periods
An affiliation period under a plan shall run concurrently
with any waiting period under the plan.
(3) Alternative methods
A health maintenance organization described in paragraph (1)
may use alternative methods, from those described in such
paragraph, to address adverse selection as approved by the State
insurance commissioner or official or officials designated by the
State to enforce the requirements of part A of title XXVII of the
Public Health Service Act [42 U.S.C. 300gg et seq.] for the State
involved with respect to such issuer.