Article 7. Preexisting Condition Provisions of California Insurance Code >> Division 2. >> Part 2. >> Chapter 1. >> Article 7.
For purposes of this article, the following definitions
shall apply:
(a) "Health benefit plan" means any group or individual policy of
health insurance, as defined in Section 106. The term does not
include coverage of Medicare services pursuant to contracts with the
United States government or coverage that provides excepted benefits
as described in Sections 2722 and 2791 of the federal Public Health
Service Act, subject to Section 10198.61.
(b) "Preexisting condition provision" means a policy provision
that excludes coverage for charges or expenses incurred during a
specified period following the insured'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.
(c) "Creditable coverage" means:
(1) Any individual or group policy, contract, or program, that is
written or administered by a health insurer, 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.
(2) The federal Medicare Program pursuant to Title XVIII of the
federal Social Security Act (42 U.S.C. Sec. 1395 et seq.).
(3) The Medicaid Program pursuant to Title XIX of the federal
Social Security Act (42 U.S.C. Sec. 1396 et seq.).
(4) Any other publicly sponsored program, provided in this state
or elsewhere, of medical, hospital, and surgical care.
(5) 10 U.S.C. Chapter 55 (commencing with Section 1071) (Civilian
Health and Medical Program of the Uniformed Services (CHAMPUS)).
(6) A medical care program of the Indian Health Service or of a
tribal organization.
(7) A health plan offered under 5 U.S.C. Chapter 89 (commencing
with Section 8901) (Federal Employees Health Benefits Program
(FEHBP)).
(8) A public health plan as defined in federal regulations
authorized by Section 2701(c)(1)(I) of the federal Public Health
Service Act, as amended by Public Law 104-191, the federal Health
Insurance Portability and Accountability Act of 1996.
(9) A health benefit plan under Section 5(e) of the federal Peace
Corps Act (22 U.S.C. Sec. 2504(e)).
(10) 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)).
(d) "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,
medical conditions.
(e) "Grandfathered health benefit plan" means a health benefit
plan that is a grandfathered health plan, as defined in Section 1251
of PPACA.
(f) "Nongrandfathered health benefit plan" means a health benefit
plan that is not a grandfathered health plan as defined in Section
1251 of PPACA.
(g) "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) For purposes of this article, "health benefit plan"
does not include policies or certificates of specified disease or
hospital confinement indemnity provided that the carrier offering
those policies or certificates complies with the following:
(1) The carrier files, on or before March 1 of each year, a
certification with the commissioner that contains the statement and
information described in paragraph (2).
(2) The certification required in paragraph (1) shall contain the
following:
(A) A statement from the carrier certifying that policies or
certificates described in this section (i) are being offered and
marketed as supplemental health insurance and not as a substitute for
coverage that provides essential health benefits as defined by the
state pursuant to Section 1302 of PPACA, and (ii) the disclosure form
as described in Section 10603 contains the following statement
prominently on the first page: "This is a supplement to health
insurance. It is not a substitute for essential health benefits or
minimum essential coverage as defined in federal law."
(B) A summary description of each policy or certificate described
in this section, including the average annual premium rates, or range
of premium rates in cases where premiums vary by age, gender, or
other factors, charged for the policies and certificates issued or
delivered in this state.
(3) In the case of a policy or certificate described in this
section and that is offered for the first time in this state for plan
years on or after January 1, 2014, the carrier files with the
commissioner the information and statement required in paragraph (2)
at least 30 days prior to the date such a policy or certificate is
issued or delivered in this state.
(b) As used in this section, "policies or certificates of
specified disease" and "policies or certificates of hospital
confinement indemnity" mean policies or certificates of insurance
sold to an insured to supplement other health insurance coverage as
specified in this section. An insurer issuing a "policy or
certificate of specified disease" or a "policy or certificate of
hospital confinement indemnity" shall require that the person to be
insured is covered by an individual or group policy or contract that
arranges or provides medical, hospital, and surgical coverage not
designed to supplement other private or governmental plans.
(a) A health benefit plan for group coverage shall not
impose any preexisting condition provision or waivered condition
provision upon any individual.
(b) (1) A nongrandfathered health benefit plan for individual
coverage shall not impose any preexisting condition provision or
waivered condition provision upon any individual.
(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 individual's effective date of coverage,
nor limit or exclude coverage for a specific insured 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 health benefit plan shall credit the time the
individual was covered under creditable coverage, provided that the
individual becomes eligible for coverage under the succeeding health
benefit plan 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 a waiting period.
This article applies to all health benefit plans that
provide benefits to residents of this state regardless of the situs
of the contract or group master policyholder.
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
factors:
(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.
(h) Disability.
(i) Any other health status-related factor as determined by any
federal regulations, rules, or guidance issued pursuant to Section
2705 of the federal Public Health Service Act.
This article shall become operative on January 1, 2014.