2023 New York Laws › ISC - Insurance › Article 43 - 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)  A  corporation  shall  not  impose  any  pre-existing   condition
exclusion  in  an  individual  or  group  contract of hospital, medical,
surgical or prescription drug expense insurance.