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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. Delaware adopts the federal requirements, but has laws that govern preexisting exclusions and limitations.
Under the Delaware Insurance code, exclusions or limitations may only apply to conditions for which medical advice or treatment was received during the 12 months prior to the effective date of coverage. Exclusions or limitations cannot apply to loss incurred or disability commencing after the earlier of:
- the end of a continuous period of 12 months beginning on or after the effective date of coverage during all of which the person has received no medical advice or treatment for a condition; and
- the end of the 2-year period beginning on the effective date of coverage.
Group health insurance policies must provide coverage for a plan participant who is hospitalized on the date coverage terminates for a period of 10 consecutive days if coverage terminates for any reason except nonpayment of premium. Benefits shall continue at the same level.
Delaware Code, Title 18, §3517
Health plans that cover a large group cannot do the following:
- Deny, exclude, or limit benefits because of a preexisting condition for losses incurred more than 12 months after enrollment, or, if earlier, the first day of the waiting period for enrollment;
- Impose any preexisting condition exclusion relating to pregnancy or adoption. For adoptions, the child must be less than 18 years old and is covered under creditable coverage.
- Establish rules for eligibility for any individual to enroll based on any health status-related factors.
Health plans that cover a large group must waive any affiliation period or time period applicable to a preexisting condition exclusion or limitation for the time individuals had previous creditable coverage, if the creditable coverage was continuous up to 63 days before the effective date of the new coverage. For purposes of calculating continuous coverage, a waiting period must not be considered a gap in coverage.
Health plans that cover a large group may do the following:
- Impose a preexisting condition exclusion only if such exclusion relates to a condition, regardless of the cause of the condition for which medical advice, diagnosis, care or treatment was recommended or received within six months immediately before the effective date of coverage;
- Impose an affiliation period, if it does not utilize preexisting condition limitations. Affiliation periods must run concurrently with a waiting period.
- Exclude coverage for late enrollees for no more than an 18-month preexisting condition exclusion; except that, if both a waiting period and a preexisting condition exclusion are applicable to a late enrollee, the combined period shall not exceed 18 months from the date the individual enrolls for coverage under the plan.
Delaware Code, Title 18, §3572