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Summary of differences between federal and state regulations
Federal HIPAA portability provisions limit exclusions for preexisting conditions; prohibit discrimination against employees and dependents based on their health status; and allow a special opportunity to enroll in a new plan to individuals in certain circumstances.
States are allowed to go beyond the federal requirements. The state regulations are called out below.
State
Contact
California Department of Insurance
Regulations
Preexisting condition provisions of health benefit plans can not exclude coverage for more than six months following the individual’s effective date of coverage and may only relate to conditions for which medical advice, diagnosis, care, or treatment, including the use of prescription medications, was recommended by or received from a licensed health practitioner during the six months immediately preceding the effective date of coverage.
A carrier that does not use a preexisting condition provision may impose a waiting or affiliation period, not to exceed 60 days, before the coverage issued shall become effective. During the waiting or affiliation period, the carrier does not have to provide health care benefits and no premiums shall be charged to the subscriber or enrollee.
In determining whether a preexisting condition provision or a waiting period applies to someone, a plan shall credit the time the person was covered under creditable coverage, provided the person becomes eligible for coverage under the succeeding plan contract within 62 days of termination of prior coverage, and applies for coverage with the succeeding health benefit plan contract within the applicable enrollment period.
A plan must also credit any time an eligible employee must wait before enrolling in the health benefit plan, including any post-enrollment or employer-imposed waiting or affiliation period. However, if a person's employment has ended, the availability of health coverage offered through employment or sponsored by an employer has terminated, or an employer's contribution toward health coverage has terminated, a plan must credit the time the person was covered under creditable coverage if the person becomes eligible for health coverage offered through employment or sponsored by an employer within 180 days, exclusive of any waiting or affiliation period, and applies for coverage under the succeeding health benefit plan within the applicable enrollment period.
Group health benefit plans may not impose a preexisting conditions exclusion to the following:
- To a newborn individual, who, as of the last day of the 30-day period beginning with the date of birth, applied for coverage through the employer-sponsored plan.
- To a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning with the date of adoption or placement for adoption, is covered under creditable coverage and applies for coverage through the employer-sponsored plan. This provision shall not apply if, for 63 continuous days, the child is not covered under any creditable coverage.
- To a condition relating to benefits for pregnancy or maternity care.
In addition to the preexisting condition exclusions and the waiting or affiliation period, carriers providing coverage to a guaranteed association may impose on employers or individuals purchasing coverage who would not be eligible for guaranteed coverage if they were not purchasing through the association a waiting or affiliation period, not to exceed 60 days, before the coverage issued shall become effective. During the waiting or affiliation period, the carrier is not required to provide health care benefits and no premiums shall be charged to the insured.
A health care provider or a health care service plan may disclose medical information to a specified type of employee welfare benefit plan formed under the Taft-Hartley Act, or to an entity contracting with that employee welfare benefit plan, as specified, if, among other requirements, the disclosure is for a specified purpose, is made pursuant to a request accompanied by a written authorization for the release of the information, as specified, and is authorized by and made in a manner consistent with HIPAA.
California Insurance Code §10708
California Civil Code §56.10, §56.11