Sec. 5. Prohibition of preexisting condition exclusions and other discrimination based on health status
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Subpart 1 of part A of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg et seq. ) is amended by striking section 2701 and inserting the following: A group health plan or a health insurance issuer offering group health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage. For purposes of this part: The term preexisting condition exclusion means, with respect to a group health plan or health insurance coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment in such plan or for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.
Genetic information shall not be treated as a preexisting condition in the absence of a diagnosis of the condition related to such information. The term date of enrollment means, with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for such enrollment. The term waiting period means, with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan.
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 is met: 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.
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. The employee's or dependent's coverage described in subparagraph (A)— was under a COBRA continuation provision and the coverage under such provision was exhausted; or 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 toward such coverage were terminated.
Under the terms of the plan, the employee requests such enrollment not later than 30 days after the date of exhaustion of coverage described in subparagraph (C)(i) or termination of coverage or employer contribution described in subparagraph (C)(ii). If— a group health plan makes coverage available with respect to a dependent of an individual; 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); and a person becomes such a dependent of the individual through marriage, birth, or adoption or placement for adoption, the group health plan shall provide for a dependent special enrollment period described in subparagraph
(B)during which the person (or, if not otherwise enrolled, the individual) may be enrolled under the plan as a dependent of the individual, and 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. A dependent special enrollment period under this subparagraph shall be a period of not less than 30 days and shall begin on the later of— the date dependent coverage is made available; or the date of the marriage, birth, or adoption or placement for adoption (as the case may be) described in subparagraph (A)(iii). If an individual seeks to enroll a dependent during the first 30 days of such a dependent special enrollment period, the coverage of the dependent shall become effective— 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; in the case of a dependent's birth, as of the date of such birth; or in the case of a dependent's adoption or placement for adoption, the date of such adoption or placement for adoption. 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 or coverage if either of the following conditions is met: The employee or dependent is covered under a Medicaid plan under title XIX of the Social Security Act or under a State child health plan under title XXI of such Act and coverage of the employee or dependent under such a plan is terminated as a result of loss of eligibility for such coverage and the employee requests coverage under the group health plan (or health insurance coverage) not later than 60 days after the date of termination of such coverage. The employee or dependent becomes eligible for assistance, with respect to coverage under the group health plan or health insurance coverage, under such Medicaid plan or State child health plan (including under any waiver or demonstration project conducted under or in relation to such a plan), if the employee requests coverage under the group health plan or health insurance coverage not later than 60 days after the date the employee or dependent is determined to be eligible for such assistance. Each employer that maintains a group health plan in a State that provides medical assistance under a State Medicaid plan under title XIX of the Social Security Act, or child health assistance under a State child health plan under title XXI of such Act, in the form of premium assistance for the purchase of coverage under a group health plan, shall provide to each employee a written notice informing the employee of potential opportunities then currently available in the State in which the employee resides for premium assistance under such plans for health coverage of the employee or the employee's dependents. For purposes of compliance with this subclause, the employer may use any State-specific model notice developed in accordance with section 701(f)(3)(B)(i)(II) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1181(f)(3)(B)(i)(II) ). An employer may provide the model notice applicable to the State in which an employee resides concurrent with the furnishing of materials notifying the employee of health plan eligibility, concurrent with materials provided to the employee in connection with an open season or election process conducted under the plan, or concurrent with the furnishing of the summary plan description as provided in section 104(b) of the Employee Retirement Income Security Act of 1974. In the case of an enrollee in a group health plan who is covered under a Medicaid plan of a State under title XIX of the Social Security Act or under a State child health plan under title XXI of such Act, the plan administrator of the group health plan shall disclose to the State, upon request, information about the benefits available under the group health plan in sufficient specificity, as determined under regulations of the Secretary of Health and Human Services in consultation with the Secretary that require use of the model coverage coordination disclosure form developed under section 311(b)(1)(C) of the Children's Health Insurance Reauthorization Act of 2009, so as to permit the State to establish (under paragraph (2)(B), (3), or
(10)of section 2105(c) of the Social Security Act or otherwise) the cost effectiveness of the State providing medical or child health assistance through premium assistance for the purchase of coverage under such group health plan and in order for the State to provide supplemental benefits required under paragraph (10)(E) of such section or other authority. A group health plan or health insurance issuer that provides coverage to an association as required under section 2711(a)(2) shall accept every qualified individual that the association seeks health insurance coverage for, without regard to the health status of such individual. For purposes of this subsection: The term association means an association that— has a constitution and bylaws; is determined by the Secretary to be an association which is operating in good faith for a primary purpose other than that of obtaining insurance; and has been in existence for a period of at least 5 years. The term dependent , with respect to a qualified individual, has the meaning given such term in section 2714, with respect to a policy holder. The term qualified actuary means a member in good standing of the American Academy of Actuaries, or a successor organization approved by the Secretary. The term qualified individual means, with respect to an association, an individual who meets any of the following: A member of the association who has been such a member for a period of at least 30 days. An employee of such member who has been employed by such member for a period of at least 30 days. An employee of the association who has been employed by the association for a period of at least 30 days. . Subpart 1 of part B of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–41 et seq. ) is amended by adding at the end the following: The provisions of section 2701 (other than subparagraphs (A)(ii) and
(B)of subsection (c)(3)) shall apply to health insurance coverage offered to individuals by a health insurance issuer in the individual market in the same manner as it applies to health insurance coverage offered by a health insurance issuer in the group market. .
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- 42 USC 300gg–41
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Sec. 5
Prohibition of preexisting condition exclusions and other discrimination based on health status
Cite42 USC 300gg–41
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