2006 New York Code - Pre-existing Condition Provisions In Health Policies.

 
    §  3232.  Pre-existing  condition provisions in health policies. Every
  individual health insurance policy and every group or  blanket  accident
  and  health insurance policy issued or issued for delivery in this state
  which includes a  pre-existing  condition  provision  shall  contain  in
  substance  the following provision or provisions which in the opinion of
  the superintendent are more favorable to the individuals, members of the
  group and their eligible dependents:
    (a) In determining whether a pre-existing condition provision  applies
  to  a covered person, the group or blanket accident and health insurance
  policy or individual health insurance policy shall credit the  time  the
  covered  person was previously covered under creditable coverage, if the
  previous creditable coverage was continuous to  a  date  not  more  than
  sixty-three  days  prior  to the enrollment date of the new coverage. In
  the case of  previous  health  maintenance  organization  coverage,  any
  affiliation  period  prior  to that previous coverage becoming effective
  shall also be credited pursuant to this subsection.
    (b) No pre-existing condition provision shall exclude coverage  for  a
  period  in  excess  of  twelve  months  following the enrollment date of
  coverage for the covered person and  may  only  relate  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 six-month period ending on the enrollment date.
  For purposes of this section "enrollment date" means the  first  day  of
  coverage  of  the  individual under the policy or, if earlier, the first
  day of the waiting period that must pass with respect to  an  individual
  before  such  individual  is  eligible to be covered for benefits. If an
  individual seeks and obtains coverage  in  the  individual  market,  any
  period  after  the  date  the  individual files a substantially complete
  application for coverage and before the  first  day  of  coverage  is  a
  waiting  period.  For purposes of this section genetic information shall
  not be treated as a pre-existing condition in the absence of a diagnosis
  of the condition related to such information. No pre-existing  condition
  limitation provision shall exclude coverage in the case of:
    (1)  an  individual  who,  as of the last day of the thirty-day period
  beginning with the date of birth, is covered under  creditable  coverage
  as defined in subsection (c) of this section;
    (2)  a  child  who  is adopted or placed for adoption before attaining
  eighteen years of age and who, as of the  last  day  of  the  thirty-day
  period  beginning on the date of the adoption or placement for adoption,
  is covered under creditable coverage as defined  in  subsection  (c)  of
  this section;
    (3)  pregnancy  (except  in an individual health insurance policy or a
  student blanket accident and health insurance policy in which an insurer
  may exclude coverage,  subject  to  a  credit  for  previous  creditable
  coverage, for a period not to exceed ten months for a pregnancy existing
  on the enrollment date); or
    (4)  an  individual,  and  any  dependent  of  such individual, who is
  eligible for a federal tax credit under  the  federal  Trade  Adjustment
  Assistance  Reform  Act  of  2002  and  who  has three months or more of
  creditable coverage.
    Paragraphs one and two of this subsection shall no longer apply to  an
  individual  after the end of the first sixty-three day period during all
  of which the individual was not covered under any creditable coverage.
    (c) For purposes of this section  "creditable  coverage"  means,  with
  respect  to  an  individual, coverage of the individual under any of the
  following:
    (1) A group health plan;
    (2) Health insurance coverage;
    (3) Part A or B of title XVIII of the Social Security Act;
    (4)  Title  XIX  of  the  Social  Security  Act,  other  than coverage
  consisting solely of benefits under section 1928;
    (5) Chapter 55 of title 10, United States Code;
    (6) A medical care program of the Indian Health Service or of a tribal
  organization;
    (7) A state health benefits risk pool;
    (8) A health plan offered under chapter 89 of title 5,  United  States
  Code;
    (9) A public health plan (as defined in regulations);
    (10)  A  health benefit plan under section 5(e) of the Peace Corps Act
  (22 U.S.C. 2504(e)).
    (d)(1) For purposes of applying the credit of such creditable coverage
  an insurer shall count a period of creditable coverage without regard to
  the specific benefits covered during the period.
    (2) Alternatively, an  insurer  may  elect  to  count  the  period  of
  creditable coverage based on coverage of benefits within each of several
  classes  or  categories  of  benefits  as specified in regulations. Such
  election shall be made on a uniform basis for all insureds, participants
  and beneficiaries. Pursuant to such election an insurer shall count  the
  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. An insurer making such election shall prominently state in any
  disclosure  statement,  and shall set forth in any policy or certificate
  issued in connection with the coverage, that the insurer has  made  such
  election.  Such  disclosure statement shall include a description of the
  effect of the election with regard  to  the  application  of  creditable
  coverage.
    (3)   Notwithstanding   the   foregoing  paragraph,  for  purposes  of
  determining the extent to which a pre-existing condition limitation  has
  been  satisfied in a policy issued pursuant to subsection (l) of section
  three thousand two hundred sixteen of this article within thirty days of
  discontinuance of a class  of  health  maintenance  organization  direct
  payment  contract  for  enrollees  whose  contract  was discontinued, an
  insurer shall credit the time that the  enrollee  was  covered  under  a
  health  maintenance organization direct payment contract issued prior to
  January first,  nineteen  hundred  ninety-six,  without  regard  to  the
  specific  benefits  covered  under  the  health maintenance organization
  contract.
    (4) With respect to an "eligible individual", as  defined  in  section
  2741(b)  of  the  federal  Public  Health  Service  Act, 42 U.S.C. § 300
  gg-41(b), an insurer may not impose any pre-existing condition exclusion
  in an individual health insurance policy. For all other covered persons,
  the pre-existing condition crediting requirement of  subsection  (a)  of
  this section shall be applicable.
    (e)  For  the  purposes  of  this section the term "group health plan"
  means an employee welfare benefit plan (as defined in  section  3(1)  of
  the  Employee Retirement Income Security Act of 1974) to the extent that
  the plan provides medical care (including items and services paid for as
  medical care) to employees or their dependents  (as  defined  under  the
  terms  of  the  plan)  directly  or  through insurance, reimbursement or
  otherwise.