28 Tex. Admin. Code § 26.306 - Exclusions, Limitations, Waiting Periods, Affiliation Periods, Preexisting Conditions, and Restrictive Riders
(a) A
large employer carrier may not exclude any eligible employee who meets the
participation criteria or an eligible dependent, if dependent coverage is
offered to enrollees under a large employer health benefit plan (including a
late enrollee, who would otherwise be covered under a large employer's health
benefit plan), except to the extent permitted under Insurance Code §§
1501.102 -
1501.106 (concerning
Preexisting Condition Provision; Treatment of Certain Conditions as Preexisting
Prohibited; Affiliation Period; Waiting Period Permitted; and Certain
Limitations or Exclusions of Coverage Prohibited) and 1501.601 - 1501.609
(concerning Participation Criteria; Coverage Requirements; Exclusion of
Eligible Employee or Dependent Prohibited; Declining Coverage; Minimum
Contribution or Participation Requirements; Employee Enrollment; Waiting
Period; Coverage for Newborn Children; Coverage for Adopted Children; and
Coverage for Unmarried Children).
(b) A preexisting condition provision in a
large employer health benefit plan may not apply to expenses incurred on or
after the expiration of the 12 months following the effective date of coverage
of the enrollee or late enrollee, except as authorized by subsection (h)(2) of
this section.
(c) A preexisting
condition provision in a large employer health benefit plan may not apply to
coverage for a disease or condition other than a disease or condition for which
medical advice, diagnosis, care, or treatment was recommended or received from
an individual licensed to provide those services under state law and operating
within the scope of practice authorized by state law during the six months
before the effective date of coverage.
(d) A large employer carrier may not treat
genetic information as a preexisting condition described by Insurance Code §
1501.102 in the
absence of a diagnosis of the condition related to the information.
(e) A large employer carrier may not treat a
pregnancy as a preexisting condition described by Insurance Code §
1501.102.
(f) A preexisting condition provision in a
large employer health benefit plan may not apply to an individual who was
continuously covered for an aggregate period of 12 months under creditable
coverage that was in effect up to a date not more than 63 days before the
effective date of coverage under the large employer health benefit plan,
excluding any waiting or affiliation period. For example, Individual A has
coverage under an individual policy for six months beginning on May 1, 2014,
through October 31, 2014, followed by a gap in coverage of 61 days until
December 31, 2014. Individual A is covered under an individual health plan
beginning on January 1, 2015, for six months through June 30, 2015, followed by
a gap in coverage of 62 days until August 31, 2015. The effective date of
Individual A's coverage under a large employer health benefit plan is September
1, 2015. Individual A has 12 months of creditable coverage and would not be
subject to a preexisting condition exclusion under the large employer health
benefit plan.
(g) In determining
whether a preexisting condition provision applies to an individual covered by a
large employer benefit plan, the large employer carrier must credit the time
the individual was covered under previous creditable coverage if the previous
coverage was in effect at any time during the 12 months preceding the effective
date of coverage under a large employer health benefit plan. If the previous
coverage was issued under a health benefit plan, any waiting or affiliation
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. The effective
date of Individual B's coverage under a large employer health insurance policy
is September 1, 2016. Under this example, since there was a significant break
in coverage, to determine the length of creditable coverage, the large 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
large employer plan. Individual B has creditable coverage of six months and the
issuer of the large employer health benefit plan may impose a preexisting
condition limitation for six months on Individual B.
(h) A large employer carrier must choose one
of the methods set forth in paragraph (1) or (2) of this subsection for
handling requests for enrollment from a late applicant in any health benefit
plan subject to this subchapter. The large employer carrier must use the same
method in regard to all health benefit plans.
(1) The employee or dependent may be excluded
from coverage and any application for coverage rejected until the next annual
open enrollment period and, on enrollment, may be subject to a 12-month
preexisting condition provision or, in the case of an HMO, may be subject to a
60-day affiliation provision, as described by Insurance Code §§
1501.102 -
1501.104.
(2) The employee or dependent's application
may be accepted immediately and the employee or dependent enrolled as a late
enrollee during the plan year, in which case the preexisting condition
provision imposed for a late enrollee may not exceed 18 months or, in the case
of an HMO, the affiliation period may not exceed 90 days, from the date of the
late enrollee's application for coverage.
(3) The provisions of paragraphs (1) and (2)
of this subsection do not apply to employees or dependents under the special
circumstances listed as exceptions under the definition of late enrollee in §
26.4 of this title (relating to
Definitions).
(4) Examples for
applying subparagraphs (A) and (B) of this paragraph, in the case of both
insurers and HMOs: Individual A requests coverage on October 1, 2014, after the
enrollment period of July 1, 2014, through July 31, 2014, has ended. The next
annual open enrollment period is July 1, 2015, through July 31, 2015. The
effective date of coverage for persons enrolling during an open enrollment
period is the beginning of the plan year, which is September 1 of each year.
(A) If the carrier is an insurer and has
elected to exclude all applicants requesting late enrollment under health
benefit plans subject to this subchapter until the next open enrollment period,
Individual A must reapply for coverage in July 2015, and the carrier may apply
up to a 12-month preexisting condition period from the effective date of
coverage and, as with any other enrollee, the preexisting condition period
would begin on September 1, 2015, and expire on September 1, 2016.
(B) If the carrier is an insurer and has
elected to immediately accept applications for late enrollment under health
benefit plans subject to this subchapter and enroll the applicant during the
plan year, the carrier may apply up to an 18-month preexisting condition period
from the date of application. If Individual A applied for coverage on October
1, 2014, the preexisting condition period would begin on that date and would
expire on April 1, 2016.
(C) If the
carrier is an HMO and has elected to exclude all applicants requesting late
enrollment under health benefit plans subject to this subchapter until the next
open enrollment period, Individual A must reapply for coverage in July 2015,
and the carrier may apply up to a 60-day affiliation period, as with any other
enrollee.
(D) If the carrier is an
HMO and has elected to immediately accept applications for late enrollment
under health benefit plans subject to this subchapter and enroll the applicant
during the plan year, the carrier may apply up to a 90-day affiliation period
from the day Individual A applied for coverage.
(i) An HMO may impose an affiliation period
if the period is applied uniformly to each enrollee 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.
(j) A large employer may establish a waiting
period under Insurance Code §
1501.606(b)
applicable to all new entrants under the health benefit plan during which a new
employee is not eligible for coverage. The large employer must determine the
duration of the waiting period. A large employer carrier may not apply a
waiting period or other similar limitation of coverage (other than an exclusion
for preexisting medical conditions or an affiliation period consistent with
Insurance Code §§
1501.102 -
1501.106 and
1501.601 -
1501.609, with respect
to a new entrant, that is longer than the waiting period established by the
large employer for all other employees. On completion of the waiting period and
enrollment within the time frame allowed by §
26.305(a) of
this title (relating to Enrollment), coverage must be effective no later than
the next premium due date. Coverage may be effective at an earlier date, as
agreed on by the large employer and the large employer carrier.
(k) A large employer health benefit plan may
not, by use of a rider or amendment applicable to a specific individual, limit
or exclude coverage by type of illness, treatment, medical condition, or
accident, except for a preexisting condition or affiliation period permitted
under Insurance Code §§
1501.102 -
1501.106 and
1501.601 -
1501.609.
(l) To determine if preexisting conditions
exist, a carrier must determine the source of previous or existing coverage of
each eligible employee meeting the participation criteria at the time the
employee or dependent initially enrolls into the health benefit plan provided
by the large employer carrier. The large employer carrier has the
responsibility to contact the source of previous or existing coverage to
resolve any questions about the benefits or limitations related to any previous
or existing coverage in the absence of a creditable coverage certification
form.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.