US Laws, Codes, Statutes & Cases

[ Text of section effective until January 1, 2007. For text effective January 1, 2007, see below.]

  Section 5. (a) No policy shall exclude any eligible employee or eligible dependent on the basis of age, occupation, actual or expected health condition, claims experience, duration of coverage, or medical condition of such person.

  (b) Preexisting conditions provisions shall not exclude coverage for a period beyond six months following the individual's effective date of coverage and may only relate to (i) conditions which had, during the six months immediately preceding the effective date of coverage, manifested themselves in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or for which medical advice, diagnosis, care or treatment was recommended or received or (ii) a pregnancy existing on the effective date of coverage.

  In determining whether a preexisting condition provision applies to an eligible employee or dependent, all health benefit plans shall credit the time such person was covered under a previous qualifying health plan provided by a carrier if the previous coverage was continuous to a date not more than thirty days prior to the effective date of the new coverage, exclusive of any applicable service waiting period under such new coverage, and if the previous qualifying coverage was reasonably actuarially equivalent to the new coverage, as determined by the commissioner.

  (c) No policy may provide for a waiting period of more than six months beyond the insured's effective date of coverage under the health benefit plan; provided, however, that a carrier may not impose any waiting period upon a new employee who had coverage under a previous qualifying health plan immediately prior to, or until, employment by the eligible small business. If a policy includes a waiting period, emergency services must be covered during the waiting period. In determining whether a waiting period applies to an eligible employee or dependent, all health benefit plans shall credit the time such person was covered under a previous qualifying health plan if the insured experiences only a temporary interruption in coverage, and if the previous qualifying coverage was reasonably actuarially equivalent to the new coverage, both as determined by the commissioner. The waiting period may only apply to services which the new plan covers, but which were not covered under the old plan.

  When a group changes from one health benefit plan to another, whether such plan is with the same carrier or a different carrier, the carrier may impose a new waiting period of not more than six months on all members of the group.

  The commissioner shall promulgate regulations to enforce the provisions of this section.

Chapter 176J: Section 5. Exclusion of eligible employees; preexisting conditions; waiting periods

[ Text of section as amended by 2006, 58, Sec. 84 effective January 1, 2007. See 2006, 58, Sec. 142. For text effective until January 1, 2007, see above.]

  Section 5. (a) No policy shall exclude any eligible individual, eligible employee or eligible dependent on the basis of age, occupation, actual or expected health condition, claims experience, duration of coverage, or medical condition of such person.

  (b) Pre-existing conditions provisions shall not exclude coverage for a period beyond 6 months following the individual's effective date of coverage and may only relate to conditions which had, during the 6 months preceding an eligible individual's, eligible employee's or eligible dependent's effective date of coverage and may only relate to 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. Pre-existing condition provisions may not apply to a pregnancy existing on the effective date of coverage. A carrier may not impose a pre-existing condition exclusion or waiting period for more than 3 months following the effective date of coverage for Trade Act/Health Coverage Tax Credit Eligible Persons.

  (c) No policy may provide for a waiting period of more than 4 months beyond the insured's effective date of coverage under the health benefit plan; but an eligible individual who has not had creditable coverage for the 18 months before the effective date of coverage shall not be subject to a waiting period, and a carrier may not impose any waiting period upon a new employee who had creditable coverage under a previous qualifying health plan immediately before, or until, employment by the eligible small business. If a policy includes a waiting period, emergency services shall be covered during the waiting period. In determining whether a waiting period applies to an eligible individual, eligible employee or dependent, all health benefit plans shall credit the time such person was covered under a previous qualifying health plan if the insured experiences only a temporary interruption in coverage, and if the previous qualifying coverage was reasonably actuarially equivalent to the new coverage, both as determined by the commissioner. The waiting period may only apply to services which the new plan covers, but which were not covered under the previous plan.

  (d) The commissioner shall adopt regulations to enforce this section.