Article 3.15. Preexisting Condition Provisions of California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 3.15.
(a) For purposes of this article, the following
definitions shall apply:
(1) "Health benefit plan" means a health care service plan
contract that provides medical, hospital, and surgical benefits. The
term does not include coverage of Medicare services pursuant to
contracts with the United States government, Medicare supplement
coverage, or coverage under a specialized health care service plan
(2) "Preexisting condition provision" means a contract provision
that excludes coverage for charges or expenses incurred during a
specified period following the enrollee's effective date of coverage,
as to a condition for which medical advice, diagnosis, care, or
treatment was recommended or received during a specified period
immediately preceding the effective date of coverage.
(3) "Creditable coverage" means:
(A) Any individual or group policy, contract, or program that is
written or administered by a health insurer, nonprofit hospital
service plan, health care service plan, fraternal benefits society,
self-insured employer plan, or any other entity, in this state or
elsewhere, and that arranges or provides medical, hospital and
surgical coverage not designed to supplement other private or
governmental plans. The term includes continuation or conversion
coverage but does not include accident only, credit, coverage for
onsite medical clinics, disability income, Medicare supplement,
long-term care insurance, dental, vision, coverage issued as a
supplement to liability insurance, insurance arising out of a workers'
compensation or similar law, automobile medical payment insurance,
or insurance under which benefits are payable with or without regard
to fault and that is statutorily required to be contained in any
liability insurance policy or equivalent self-insurance.
(B) The Medicare Program pursuant to Title XVIII of the federal
Social Security Act (42 U.S.C. Sec. 1395 et seq.).
(C) The Medicaid Program pursuant to Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(D) Any other publicly sponsored program, provided in this state
or elsewhere, of medical, hospital, and surgical care.
(E) 10 U.S.C. Chapter 55 (commencing with Section 1071) (Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS)).
(F) A medical care program of the Indian Health Service or of a
(G) A health plan offered under 5 U.S.C. Chapter 89 (commencing
with Section 8901) (Federal Employees Health Benefits Program
(H) A public health plan as defined in federal regulations
authorized by Section 2701(c)(1)(I) of the Public Health Service Act,
as amended by Public Law 104-191, the Health Insurance Portability
and Accountability Act of 1996.
(I) A health benefit plan under Section 5(e) of the Peace Corps
Act (22 U.S.C. Sec. 2504(e)).
(J) Any other creditable coverage as defined by subsection (c) of
Section 2704 of Title XXVII of the federal Public Health Service Act
(42 U.S.C. Sec. 300gg-3(c)).
(4) "Waivered condition provision" means a contract provision that
excludes coverage for charges or expenses incurred during a
specified period of time for one or more specific, identified,
(5) "Affiliation period" means a period that, under the terms of
the health benefit plan, must expire before health care services
under the plan become effective.
(6) "Waiting period" means a period that is required to pass with
respect to an employee before the employee is eligible to be covered
for benefits under the terms of the plan.
(7) "Grandfathered health benefit plan" means a health benefit
plan that is a grandfathered health plan, as defined in Section 1251
(8) "Nongrandfathered health benefit plan" means a health benefit
plan that is not a grandfathered health plan as defined in Section
1251 of PPACA.
(9) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152), and
any rules, regulations, or guidance issued pursuant to that law.
(a) A health benefit plan for group coverage shall not
impose any preexisting condition provision or waivered condition
provision upon any enrollee.
(b) (1) A nongrandfathered health benefit plan for individual
coverage shall not impose any preexisting condition provision or
waivered condition provision upon any enrollee.
(2) A grandfathered health benefit plan for individual coverage
shall not exclude coverage on the basis of a waivered condition
provision or preexisting condition provision for a period greater
than 12 months following the enrollee's effective date of coverage,
nor limit or exclude coverage for a specific enrollee by type of
illness, treatment, medical condition, or accident, except for
satisfaction of a preexisting condition provision or waivered
condition provision pursuant to this article. Waivered condition
provisions or preexisting condition provisions contained in
individual grandfathered health benefit plans may relate only to
conditions for which medical advice, diagnosis, care, or treatment,
including use of prescription drugs, was recommended or received from
a licensed health practitioner during the 12 months immediately
preceding the effective date of coverage.
(3) If Section 5000A of the Internal Revenue Code, as added by
Section 1501 of PPACA, is repealed or amended to no longer apply to
the individual market, as defined in Section 2791 of the Public
Health Service Act (42 U.S.C. Sec. 300gg-91), paragraph (1) shall
become inoperative 12 months after the date of that repeal or
amendment and thereafter paragraph (2) shall apply also to
nongrandfathered health benefit plans for individual coverage.
(4) In determining whether a preexisting condition provision or a
waivered condition provision applies to an individual under this
subdivision, a plan shall credit the time the individual was covered
under creditable coverage, provided that the individual becomes
eligible for coverage under the succeeding plan contract within 62
days of termination of prior coverage and applies for coverage under
the succeeding plan within the applicable enrollment period.
(c) A health benefit plan for group or individual coverage shall
not impose any waiting or affiliation period.
A health benefit plan for group coverage shall not
establish rules for eligibility, including continued eligibility, of
an individual, or dependent of an individual, to enroll under the
terms of the plan based on any of the following health status-related
(a) Health status.
(b) Medical condition, including physical and mental illnesses.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions arising out of
acts of domestic violence.
(i) Any other health status-related factor as determined by any
federal regulations, rules, or guidance issued pursuant to Section
2705 of the Public Health Service Act.
This article shall become operative on January 1, 2014.