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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. Montana law governs preexisting conditions, which mirrors the requirements of federal HIPAA:
Group health plans may not exclude coverage for a preexisting condition unless:
- Medical advice, diagnosis, care, or treatment was recommended or received by the participant or beneficiary within the six-month period ending on the enrollment date;
- Exclusion of coverage extends for a period of not more than 12 months or 18 months in the case of a late enrollee; and
- The period of the preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.
In addition, genetic information may not be excluded as a preexisting condition in the absence of a diagnosis of the condition related to the genetic information. Also, pregnancy may not be excluded as a preexisting condition.
There are also laws for certificates of creditable coverage, including the following:
- A 63-day period must be counted from the date that the certificate of creditable coverage was issued to the individual. §33-22-141
- The time that an individual is in a waiting period for coverage under a group health plan or for group health insurance coverage or is in an affiliation period, may not be considered in determining the 63-day period. §33-22-141
- Group health plans must count a period of creditable coverage without regard to the specific benefits coverage during the period. §33-22-141
The law applies to the following for special enrollment periods (not exhaustive):
- Employees or dependents who were covered under a group health plan or had health insurance coverage at the time that coverage was previously offered to the employee or dependent. §33-22-523
- Employees who stated in writing at the 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 health insurance issuer required the statement at the time and provided the employee with notice of the requirement and the consequences of the requirement at the time. §33-22-523
- The employee's or dependent's coverage was under COBRA and was exhausted or not under COBRA and was terminated as a result of loss of eligibility for the coverage or because employer contributions toward the coverage were terminated. §33-22-523
- The employee requests the enrollment not later than 30 days after the date of exhaustion of coverage. §33-22-523
State
Contact
State Auditor’s Office, Insurance Division
Regulations
Montana Code Annotated
Title 33 Insurance and Insurance Companies, Chapter 22 Disability Insurance, Part 5 Group Disability Insurance
§33-22-514 Preexisting conditions relating to group market: http://leg.mt.gov/bills/mca/33/22/33-22-514.htm
§33-22-141 Crediting previous coverage: http://leg.mt.gov/bills/mca/33/22/33-22-141.htm
§33-22-142 Certificates of creditable coverage: http://leg.mt.gov/bills/mca/33/22/33-22-142.htm
§33-22-523 Special enrollment periods: http://leg.mt.gov/bills/mca/33/22/33-22-523.htm