RS 22:1062

§1062. Increased portability through limitation on preexisting condition exclusions A. Limitation on preexisting condition exclusion period; crediting for periods of previous coverage. Subject to the provisions of Subsection D of this Section, a group health plan, and a health insurance issuer offering group health insurance coverage, may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if: (1) Such exclusion relates 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. (2) Such exclusion extends for a period of not more than twelve months, or eighteen months in the case of a late enrollee, after the enrollment date. (3) The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, if any, as defined in R.S. 22:1061(4) applicable to the participant or beneficiary as of the enrollment date. B.(1) A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a group health plan, if, after such period and before the enrollment date, there was a sixty-three day period during all of which the individual was not covered under any creditable coverage. (2) For purposes of Paragraph (1) of this Subsection and Paragraph (D)(4) of this Section, any period that an individual is in a waiting period for any coverage under a group health plan, or for group health insurance coverage, or is in an affiliation period, shall not be taken into account in determining the continuous period. (3)(a) Except as otherwise provided under Paragraph (2) of this Subsection, a group health plan, and a health insurance issuer offering group health insurance coverage, shall count a period of creditable coverage without regard to the specific benefits covered during the period. (b) A group health plan, or a health insurance issuer offering group health insurance, may elect to count a period of creditable coverage based on coverage of benefits within each of several classes or categories of benefits specified in regulations promulgated by the commissioner. Such election shall be made on a uniform basis for all participants and beneficiaries. Under such election a group health plan or issuer 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. (c) In the case of an election with respect to a group health plan under Subparagraph (b) of this Paragraph, whether or not health insurance coverage is provided in connection with such plan, the plan shall: (i) Prominently state in any disclosure statements concerning the plan, and state to each enrollee at the time of enrollment under the plan, that the plan has made such election. (ii) Include in such statements a description of the effect of this election. (d) In the case of an election under Subparagraph (b) of this Paragraph with respect to health insurance coverage offered by an issuer in the small or large group market, the issuer: (i) Shall prominently state in any disclosure statements concerning the coverage, and to each employer at the time of the offer or sale of the coverage, that the issuer has made such election. (ii) Shall include in such statements a description of the effect of such election. (4) Periods of creditable coverage with respect to an individual shall be established through presentation of certifications described in Subsection E of this Section or in such other manner as may be specified in regulations. C. Except as provided in Paragraph (4) of this Subsection, a group health plan and a health insurance issuer offering group health insurance coverage may not impose any preexisting condition exclusion: (1) In the case of an individual who, as of the last day of the thirty-day period beginning with the date of birth, is covered under creditable coverage. (2) In the case of 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. This Paragraph shall not apply to coverage before the date of such adoption or placement for adoption. (3) Relating to pregnancy as a preexisting condition. (4) Paragraphs (1) and (2) of this Subsection shall not 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. D.(1) A group health plan, and a health insurance issuer offering group health insurance coverage, shall send the certification of the period of creditable coverage no more than twenty days after such certification is requested by an individual who ceases to be covered under the issuer's policy or plan. (2) The certification shall include a written certification of the following: (a) The period of creditable coverage of the individual under such plan and the coverage, if any, under such COBRA continuation provision. (b) The waiting period, if any, and affiliation period if applicable, imposed with respect to the individual for any coverage under such plan. (3) To the extent that medical care under a group health plan consists of group health insurance coverage, the plan is deemed to have satisfied the certification requirement under Paragraphs (1) and (2) of this Subsection if the health insurance issuer offering the coverage provides for such certification in accordance therewith. (4) A plan or issuer providing certification of coverage of an individual pursuant to an election under Subparagraph (B)(3)(b): (a) Upon request of the succeeding plan or issuer, shall promptly disclose to such requesting plan or issuer information on coverage of classes and categories of health benefits available under such entity's plan or coverage. (b) May charge the requesting plan or issuer for the reasonable cost of disclosing such information. (5) The commissioner of insurance shall take all appropriate measures to prevent an entity's failure to provide information under this Subsection with respect to previous coverage of an individual from adversely affecting any subsequent coverage of the individual under another group health plan or health insurance coverage. Such measures shall include enforcement of all applicable state and federal laws and regulations and adoption of any reasonable regulations required for the enforcement thereof. E.(1) A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, shall permit an employee who is eligible, but not enrolled, for coverage under the terms of the plan, or a dependent of such an employee if the dependent is eligible, but not enrolled, for coverage under such terms, to enroll for coverage under the terms of the plan if each of the following conditions are met: (a) The employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent. (b) The employee stated in writing at such time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or issuer, if applicable, required such a statement at such time and provided the employee with notice of such requirement, and the consequences of such requirement, at such time. (c) The employee's or dependent's coverage described in Subparagraph (a) of this Paragraph. (i) Was under a COBRA continuation provision and the coverage under such provision was exhausted. (ii) Was not under such a provision and either the coverage was terminated as a result of loss of eligibility for the coverage, including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, or employer contributions towards such coverage were terminated. (d) Under the terms of the plan, the employee requests such enrollment not later than thirty days after the date of exhaustion of coverage described in Item (c)(i) of this Paragraph or termination of coverage or employer contribution described in Item (c)(ii) of this Paragraph. (2)(a) Subject to eligibility requirements of group coverage pursuant to state law, a group health plan shall provide for a dependent special enrollment period during which the person, or, if not otherwise enrolled, the individual, may be enrolled under the plan as a dependent of the individual, if: (i) A group health plan makes coverage available with respect to a dependent of an individual. (ii) The individual is a participant under the plan, or has met any waiting period applicable to becoming a participant under the plan and is eligible to be enrolled under the plan but for a failure to enroll during a previous enrollment period. (iii) A person becomes such a dependent of the individual through marriage, birth, or adoption or placement for adoption. In the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a dependent of the individual if such spouse is otherwise eligible for coverage. (iv) The dependent child was enrolled in the Louisiana Children's Health Insurance Program or a Medicaid program prior to requesting enrollment in the group health plan, but is no longer eligible to be covered under either the Louisiana Children's Health Insurance Program or a Medicaid program. (b) A dependent special enrollment period under this Paragraph shall be a period of not less than thirty days and shall begin on: (i) In the case of marriage, adoption, or placement for adoption, the later of the following: the date dependent coverage is made available or the date of the marriage, adoption, or placement for adoption of a child, as the case may be. (ii) In the case of a dependent child losing eligibility for coverage by the Louisiana Children's Health Insurance Program or a Medicaid program, the later of the following: the date dependent coverage is made available or the date when coverage under the Louisiana Children's Health Insurance Program or a Medicaid program ceases. (c) If an individual seeks to enroll a dependent during the first thirty days of such a dependent special enrollment period, the coverage of the dependent shall become effective as follows: (i) In the case of marriage, not later than the first day of the first month beginning after the date the completed request for enrollment is received. (ii) In the case of a dependent's adoption or placement for adoption, the date of such adoption or placement for adoption. (iii) In the case of a dependent losing eligibility for coverage by the Louisiana Children's Health Insurance Program or a Medicaid program, the date when such coverage ceases. F.(1) A health maintenance organization which offers health insurance coverage in connection with a group health plan and which does not impose any preexisting condition exclusion allowed under Subsection A of this Section with respect to any particular coverage option may impose an affiliation period for such coverage option, but only if the following apply: (a) Such period is applied uniformly without regard to any health status-related factors. (b) Such period does not exceed two months or three months in the case of a late enrollee. (2) An affiliation period shall begin on the enrollment date and shall run concurrently with any waiting period under the plan. (3) A health maintenance organization may use alternative methods to address adverse selection following approval by the commissioner. Acts 1997, No. 1138, §1, eff. July 14, 1997; Acts 2004, No. 269, §1, eff. June 15, 2004; Acts 2005, No. 47, §1, eff. June 16, 2005; Acts 2006, No. 348, §1, eff. June 13, 2006; Redesignated from R.S. 22:250.2 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 919, §1, eff. Jan. 1, 2011; Acts 2016, No. 68, §1, eff. May 10, 2016. NOTE: Former R.S. 22:1062 redesignated as R.S. 22:842 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.