41.04 - Pre-existing Condition Limitations and Waiting Periods

41.04. Pre-existing Condition Limitations and Waiting Periods

(1) No Carrier may exclude any Eligible Individual or Eligible Dependent from a Closed Guaranteed Issue Health Plan on the basis of an actual or expected health condition of such person.

(2) No Carrier may modify the coverage of an Eligible Individual or Eligible Dependent through riders or endorsements, or otherwise restrict or exclude coverage for certain diseases or medical conditions otherwise covered by a Closed Guaranteed Issue Health Plan.

(3) For Eligible Dependents added to a Closed Plan or a Closed Guaranteed Issue Health Plan, a Carrier may, but is not required to, impose either a provision for a Pre-existing Condition Limitation or a provision for a Waiting Period, provided that:

(a) The Pre-existing Condition Limitation or Waiting Period does not limit or exclude coverage for a period beyond six months following the Eligible Dependent's effective date of coverage.

(b) No Pre-existing Condition Limitation or Waiting Period may apply to a Trade Act/Health Coverage Tax Credit-eligible person.

(c) If a policy includes a Waiting Period, emergency services shall be covered during the Waiting Period.

(4) In determining whether a Pre-existing Condition Limitation or Waiting Period applies to an Eligible Dependent:

(a) If the person meets the requirements of an eligible individual as defined in § 2741 of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 300gg - 41(b) and requests coverage in a Closed Guaranteed Issue Health Plan within 63 days of termination of any prior creditable coverage, the Carrier shall make his or her coverage effective within 30 days of the date of the application, subject to the reasonable verification of eligibility, without any Pre-existing Condition Limitations or Waiting Periods.

(b) If the person does not meet the requirements of an eligible individual as defined in § 2741 of the Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. § 300gg - 41(b) and requests coverage in a Closed Guaranteed Issue Health Plan, the Carrier may impose either a Pre-existing Condition Limitation for no more than six months or a Waiting Period, which shall be applied uniformly without regard to any health status-related factors, for no more than six months following the person's effective date of coverage; provided, that all Closed Guaranteed Issue Health Plans must credit the time such person was covered under prior creditable coverage provided by a Carrier if the previous coverage was continuous to a date not more than 63 days prior to the date of the request for the new coverage and if the previous coverage was reasonably actuarially equivalent to the new coverage. If prior creditable coverage is not reasonably actuarially equivalent to the new coverage, the covered person must receive the benefits of the previous health benefit plan during the term of the Pre-existing Condition period or Waiting Period. If the previous coverage is under Medicare or Medicaid, the previous coverage is presumed to be reasonably actuarially equivalent to the new health benefit plan.

(5) If a policy includes a Waiting Period, treatment for an emergency medical condition must be covered during the Waiting Period.

(6) Any Pre-existing Condition Limitation or Waiting Period may not extend more than six months beyond the insured's effective date of coverage, and in no event may a Carrier impose both a Pre-existing Condition Limitation and a Waiting Period.

(7) For the purposes of 211 CMR 41.04(4), "effective date of coverage" is defined as the date the individual is enrolled by the Carrier in the health benefit plan.

The following state regulations pages link to this page.