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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. Texas law generally follows federal requirements in regard to previous plan coverage for 12 months or more, and 63 days or less between jobs, and the new health plan covering pre-existing conditions immediately. It also follows the requirements if a participant was under a previous plan for less than 12 months, their waiting period is reduced by one month for every month of creditable coverage during the preceding 12 months. State law includes the following provisions:
- The plan must provide a certification of coverage. (§1205.002)
- Preexisting conditions exclusions are for those for which medical advice, diagnosis, care, or treatment was recommended or received during the six months before the earlier of: (1) the effective date of coverage; or (2) the first day of the waiting period. (§1501.102)
- A preexisting condition provision in a small or large employer health benefit plan may not apply to expenses incurred on or after the first anniversary of the initial effective date of coverage of the enrollee, including a late enrollee. (§1501.102)
- A preexisting condition provision may not apply to an individual who was continuously covered for an aggregate period of 12 months under creditable coverage that was in effect until a date not more than 63 days before the effective date of coverage under the plan, excluding any waiting period. (§1501.102)
- The plan may not treat genetic information as a preexisting condition in the absence of a diagnosis of the condition related to the information. (§1501.103)
- The plan may not treat pregnancy as a preexisting condition. (§1501.103)
- The plan may not limit or exclude coverage by type of illness, treatment, medical condition, or accident. (§1501.106)
- The initial enrollment period for employees meeting the participation criteria under a large employer health benefit plan must be at least 31 days, with a 31-day annual open enrollment period. (§1501.606)
- The initial enrollment period under a small employer health benefit plan for employees and dependents must be at least 31 days, with a 31-day open enrollment period provided annually. (§1501.156)
- Small employer health benefit plan issuers may offer a small employer the option of a plan for which he employer is required to contribute 100 percent of the premium paid. (§1501.153(a-1))
State
Contact
Regulations
Texas Insurance Code, Title 8, Subtitle A, Chapter 1205 Certification of Creditable Coverage
Texas Insurance Code, Title 8, Subtitle G, Chapter 1501 Health Insurance Portability and Availability Act
Federal
Contact
Centers for Medicare & Medicaid Services
Regulations
45 CFR Parts 160 - 164
29 CFR 2590.701-1et seq.