(a) A group health plan, and a health insurance issuer offering group health insurance coverage, may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if:
Terms Used In Tennessee Code 56-7-2803
Beneficiary: A person who is entitled to receive the benefits or proceeds of a will, trust, insurance policy, retirement plan, annuity, or other contract. Source: OCC
Creditable coverage: means , with respect to an individual, coverage of the individual under any of the following: (i) A group health plan. See Tennessee Code 56-7-2802
Enrollment date: 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 the enrollment. See Tennessee Code 56-7-2802
Group health insurance coverage: means , in connection with a group health plan, health insurance coverage offered in connection with the plan. See Tennessee Code 56-7-2802
Group health plan: means an employee welfare benefit plan, as defined in ERISA, §. See Tennessee Code 56-7-2802
Health insurance coverage: means benefits consisting of medical care, provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care, under any policy, certificate, or agreement offered by a health insurance issuer. See Tennessee Code 56-7-2802
Health insurance issuer: means an entity subject to the insurance laws of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide health insurance coverage, including, but not limited to, an insurance company, a health maintenance organization and a nonprofit hospital and medical service corporation. See Tennessee Code 56-7-2802
Large group market: means the health insurance market under which individuals obtain health insurance coverage, directly or through any arrangement, on behalf of themselves and their dependents, through a group health plan maintained by a large employer. See Tennessee Code 56-7-2802
Late enrollee: means , with respect to coverage under a group health plan, a participant or beneficiary who enrolls under the plan other than during: (A) The first period in which the individual is eligible to enroll under the plan. See Tennessee Code 56-7-2802
Medical care: means amounts paid for:(A) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body. See Tennessee Code 56-7-2802
Person: means any association, aggregate of individuals, business, company, corporation, individual, joint-stock company, Lloyds-type organization, organization, partnership, receiver, reciprocal or interinsurance exchange, trustee or society. See Tennessee Code 56-16-102
Preexisting condition exclusion: means , with respect to 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 for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date. See Tennessee Code 56-7-2802
State: when applied to the different parts of the United States, includes the District of Columbia and the several territories of the United States. See Tennessee Code 1-3-105
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. See Tennessee Code 56-7-2802
written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
(1) The exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date;(2) The exclusion extends for a period of not more than twelve (12) months, or eighteen (18) months in the case of a late enrollee, after the enrollment date; and(3) The period of the preexisting condition exclusion is reduced by the aggregate of periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.(b) A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a group health plan, if, after the period and before the enrollment date, there was a sixty-three-day period during all of which the individual was not covered under any creditable coverage.(c) Any period that an individual is in a waiting period for any coverage under a group health plan, or for group health insurance coverage, or is in an affiliation period shall not be taken into account in determining the continuous period under subsection (b).(d)Method of Crediting Coverage.(1)Standard Method. Except as otherwise provided under subdivision (d)(2), a group health plan, and a health insurance issuer offering group health insurance coverage, shall count a period of creditable coverage without regard to the specific benefits covered during the period.(2)Election of Alternative Method. A group health plan, or a health insurance issuer offering group health insurance, may elect to credit coverage based on coverage of benefits within each of several classes or categories of benefits specified in regulations rather than as provided under subdivision (d)(1). The election shall be made on a uniform basis for all participants and beneficiaries. Under the election a group health plan or issuer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within the class or category.(3) In the case of an election with respect to a group health plan under subdivision (d)(2), whether or not health insurance coverage is provided in connection with the plan, the plan shall:
(A) Prominently state in any disclosure statements concerning the plan, and state to each enrollee at the time of enrollment under the plan, that the plan has made the election; and(B) Include in the statements a description of the effect of this election.(4)Issuer Notice. In the case of an election under subdivision (d)(2) with respect to health insurance coverage offered by an issuer in the small or large group market, the issuer:
(A) Shall prominently state in any disclosure statements concerning the coverage, and to each employer at the time of the offer or sale of the coverage, that the issuer has made the election; and(B) Shall include in the statements a description of the effect of the election.(e)Establishment of Period. Periods of creditable coverage with respect to an individual shall be established through presentation of certifications described in subsection (g) or in any other manner specified in regulations.(f)Exceptions.(1) Subject to subdivision (f)(4), a group health plan, and a health insurance issuer offering group health insurance coverage, may not impose any preexisting condition exclusion in the case of an individual who, as of the last day of the thirty-day period beginning with the date of birth, is covered under creditable coverage.(2) Subject to subdivision (f)(4), a group health plan, and a health insurance issuer offering group health insurance coverage, may not impose any preexisting condition exclusion in the case of a child who is adopted or placed for adoption before attaining eighteen (18) years of age and who, as of the last day of the thirty-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This subdivision (f)(2) shall not apply to coverage before the date of the adoption or placement for adoption.(3) A group health plan, and a health insurance issuer offering group health insurance coverage, may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition.(4) Subdivisions (f)(1) and (2) shall no longer apply to an individual after the end of the first sixty-three-day period during all of which the individual was not covered under any creditable coverage.(g)Certifications and Disclosures of Coverage.(1) A group health plan, and a health insurance issuer offering group health insurance coverage, shall provide the certification described in subdivision (g)(2):
(A) At the time an individual ceases to be covered under the plan or otherwise becomes covered under a COBRA continuation provision;(B) In the case of an individual becoming covered under a COBRA continuation provision, at the time the individual ceases to be covered under the provision; and(C) On request on behalf of an individual made not later than twenty-four (24) months after the date of cessation of the coverage described in subdivision (g)(1)(A) or (B), whichever is later. The certification under subdivision (g)(1)(A) may be provided, to the extent practicable, at a time consistent with notices required under any applicable COBRA continuation provision.(2) The certification described in this subsection (g) is a written certification of:
(A) The period of creditable coverage of the individual under the plan and the coverage, if any, under the COBRA continuation provision; and(B) The waiting period, if any, and affiliation period, if applicable, imposed with respect to the individual for any coverage under the plan.(3) To the extent that medical care under a group health plan consists of group health insurance coverage, the plan is deemed to have satisfied the certification requirement under this subsection (g) if the health insurance issuer offering the coverage provides for the certification in accordance with this subsection (g).(4)Disclosure of Information on Previous Benefits. In the case of an election described in subdivision (d)(2) by a group health plan or health insurance issuer, if the plan or issuer enrolls an individual for coverage under the plan and the individual provides a certification of coverage of the individual under subdivision (g)(1):
(A) Upon request of the plan or issuer, the entity that issued the certification provided by the individual shall promptly disclose to the requesting plan or issuer information on coverage of classes and categories of health benefits available under the entity’s plan or coverage; and(B) The entity may charge the requesting plan or issuer for the reasonable cost of disclosing the information.(5)Regulations. The commissioner is authorized to establish rules to prevent an entity’s failure to provide information with respect to previous coverage of an individual from adversely affecting any subsequent coverage of the individual under another group health plan or health insurance coverage.(h)Special enrollment periods.(1)For Individuals Losing Other Coverage. As used in this subsection (h), “health insurance coverage” includes the TennCare program as administered by the department of finance and administration.(2) 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 the employee if the dependent is eligible but not enrolled for coverage under the terms, to enroll for coverage under the terms of the plan if each of the following conditions is met:
(A) 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;(B) The employee 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 issuer, if applicable, required the statement at the time and provided the employee with notice of the requirement, and the consequences of the requirement, at that time;(C) The employee’s or dependent’s coverage described in subdivision (h)(2)(A):
(i) Was under a COBRA continuation provision and the coverage under the provision was exhausted; or(ii) 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 the coverage were terminated; and(D) Under the terms of the plan, the employee requests enrollment not later than thirty (30) days after one (1) of the events described in subdivision (h)(2)(C).(3)For Dependents.(A) In general, the group health plan shall provide for a dependent special enrollment period described in subdivision (h)(3)(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 the spouse is otherwise eligible for coverage, if:
(i) A group health plan makes coverage available with respect to a dependent of an individual;(ii) 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(iii) A person becomes a dependent of the individual through marriage, birth, or adoption or placement for adoption.(B)Dependent Special Enrollment Period. A dependent special enrollment period under this subsection (h) shall be a period of not less than thirty (30) days and shall begin on the later of:
(i) The date dependent coverage is made available; or(ii) The date of the marriage, birth, or adoption or placement for adoption, as the case may be, described in subdivision (h)(3)(A)(iii).(C)No Waiting Period. If an individual seeks to enroll a dependent during the first thirty (30) days of a dependent special enrollment period, the coverage of the dependent shall become effective:
(i) 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;(ii) In the case of a dependent’s birth, as of the date of birth; or(iii) In the case of a dependent’s adoption or placement for adoption, the date of the adoption or placement for adoption.(i)Use of Affiliation Period by HMOs as an Alternative to Preexisting Condition Exclusion.(1) An HMO that offers health insurance coverage in connection with a group health plan and that does not impose any preexisting condition exclusion allowed under subsection (a) with respect to any particular coverage option may impose an affiliation period for the coverage option, but only if:
(A) The period is applied uniformly without regard to any health status-related factors; and(B) The period does not exceed two (2) months, or three (3) months in the case of a late enrollee.(2) An HMO may use alternative methods from those described in subdivision (i)(1) to address adverse selection as approved by the commissioner.
