2012 New York Consolidated Laws
ISC - Insurance
Article 43 - (4301 - 4327) NON-PROFIT MEDICAL AND DENTAL INDEMNITY, OR HEALTH AND HOSPITAL SERVICE CORPORATIONS
4318 - Pre-existing condition provisions.

 
    §  4318.  Pre-existing  condition  provisions. Every individual health
  insurance contract and  every  group  or  blanket  accident  and  health
  insurance  contract  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 individuals, members of  the  group
  and their eligible dependents:
    (a)  In determining whether a pre-existing condition provision applies
  to a covered person, the contract 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 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  contract  or,  if  earlier, the first day of the
  waiting period that must pass with respect to an individual  before  the
  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 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 direct payment  contract  or  a
  student  blanket  accident  and  health  insurance  contract  in which a
  corporation 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, a corporation shall count  a  period  of  creditable  coverage
  without regard to the specific benefits covered during the period.
    (2)  Alternatively,  a  corporation  may  elect to count the period of
  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  subscribers, participants and
  beneficiaries. Pursuant to such election a  corporation  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.  A corporation making such election shall prominently state in
  any disclosure statement,  and  shall  set  forth  in  any  contract  or
  certificate issued in connection with the coverage, that the corporation
  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 contract issued pursuant to  section  four  thousand
  three  hundred  twenty-one  or four thousand three hundred twenty-two of
  this article within thirty days of discontinuance of a class  of  health
  maintenance  organization  direct  payment  contract for enrollees whose
  contract was discontinued, a corporation shall credit the coverage of an
  enrollee 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.  §
  300gg-41(b), a corporation may not  impose  any  pre-existing  condition
  exclusion  in  an  individual  health  insurance contract. 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.
    (f) With respect to an individual under age  nineteen,  a  corporation
  may  not impose any pre-existing condition exclusion in an individual or
  group contract of  hospital,  medical,  surgical  or  prescription  drug
  expense  insurance  pursuant  to the requirements of section 2704 of the
  Public Health Service Act, 42 U.S.C. § 300gg-3,  as  made  effective  by
  section  1255(2)  of  the  Affordable Care Act, except for an individual
  under age nineteen covered under an  individual  contract  of  hospital,

  medical,  surgical  or  prescription  drug  expense  insurance that is a
  grandfathered health plan.
    (g)  Beginning  January  first,  two  thousand  fourteen,  pursuant to
  section 2704 of the Public Health Service Act, 42 U.S.C.  §  300gg-3,  a
  corporation  may  not  impose any pre-existing condition exclusion in an
  individual  or  group  contract  of  hospital,  medical,   surgical   or
  prescription  drug  expense  insurance  except in an individual contract
  that is a grandfathered health plan.
    (h) The requirements of subsections (f) and (g) of this section  shall
  also  be applicable to a blanket contract of hospital, medical, surgical
  or prescription drug expense insurance.
    (i)  For  purposes  of  subsections  (f)  and  (g)  of  this  section,
  "grandfathered  health plan" means coverage provided by a corporation in
  which an individual was enrolled on March twenty-third, two thousand ten
  for as long as the coverage maintains grandfathered status in accordance
  with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).