W. Va. Code R. § 114-54-3

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-54-3 - Limitations on Preexisting Condition Exclusion Period

3.1. Subject to subsection 3.2 of this rule, a health insurer may impose a preexisting condition exclusion with respect to an individual covered under a health benefit plan only if medical advice, diagnosis, care or treatment for the condition was recommended or received within the six-month period which began on the six-month anniversary date preceding the individual's enrollment date and ends on the enrollment date.

a. Medical advice, diagnosis, care or treatment is taken into account only if it is recommended by, or received from, a medical care provider.

b. Genetic information is not a preexisting condition unless a condition related to the information has been diagnosed.

c. Pregnancy may not be excluded from coverage as a preexisting condition.

3.2. Unless the child has had a significant break in coverage, no preexisting condition exclusion may be imposed with regard to a child who:

a. Is covered under any creditable coverage as of the last day of the thirty-day period beginning with the date of birth; or

b. Is adopted or placed for adoption before attaining the age of eighteen years 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 subdivision does not apply to coverage before the date of adoption or placement for adoption.

3.3. A preexisting condition exclusion may not extend for more than a twelve-month period (eighteen-month period for a late enrollee) beginning on an individual's enrollment date.

3.4. Any preexisting condition exclusion otherwise applicable to an individual shall be reduced by the number of days of creditable coverage the individual has as of the enrollment date, as provided in sections four and five of this rule.

3.5. A health maintenance organization that imposes no preexisting condition exclusions under a health benefit plan issued in connection with a particular group health plan may:

a. Impose an affiliation period if the affiliation period is applied uniformly without regard to any health status-related factors and does not exceed two months (three months for a late enrollee); or

b. File with the commissioner a proposal for an alternative method to address adverse selection, but no alternative method may be used unless approved by the commissioner.

3.6. With respect to individuals enrolled under a group health plan on the effective date of this rule for the group health plan, a health insurer may not impose a preexisting condition exclusion to the extent that:

a. An individual has met an exclusion period permitted under this section; or

b. On the effective date of this rule for the group health plan, an individual uses creditable coverage that the individual had as of his or her enrollment date in the group health plan to reduce an exclusion period permitted under this subsection.

W. Va. Code R. § 114-54-3