New York Laws
Article 43 - Non-Profit Medical and Dental Indemnity, or Health and Hospital Service Corporations
4318 - Pre-Existing Condition Provisions.

(a) In determining whether a pre-existing condition provision applies
to a covered person, the contract shall credit the time the covered
person was previously covered under creditable coverage, if the previous
creditable coverage was continuous to a date not more than sixty-three
days prior to the enrollment date of the new coverage. In the case of
previous health maintenance organization coverage, any affiliation
period prior to that previous coverage becoming effective shall also be
credited pursuant to this subsection.
(b) No pre-existing condition provision shall exclude coverage for a
period in excess of twelve months following the enrollment date for the
covered person and may only relate 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. For purposes of this
section "enrollment date" means the first day of coverage of the
individual under the contract or, if earlier, the first day of the
waiting period that must pass with respect to an individual before the
individual is eligible to be covered for benefits. If an individual
seeks and obtains coverage in the individual market, any period after
the date the individual files a substantially complete application for
coverage and before the first day of coverage is a waiting period. For
purposes of this section, genetic information shall not be treated as a
pre-existing condition in the absence of a diagnosis of the condition
related to such information. No pre-existing condition provision shall
exclude coverage in the case of:
(1) an individual who, as of the last day of the thirty-day period
beginning with the date of birth, is covered under creditable coverage
as defined in subsection (c) of this section;
(2) a child who is adopted or placed for adoption before attaining
eighteen 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 as defined in subsection (c) of
this section;
(3) pregnancy (except in an individual direct payment contract or a
student blanket accident and health insurance contract in which a
corporation may exclude coverage, subject to a credit for previous
creditable coverage, for a period not to exceed ten months for a
pregnancy existing on the enrollment date); or
(4) an individual, and any dependent of such individual, who is
eligible for a federal tax credit under the federal Trade Adjustment
Assistance Reform Act of 2002 and who has three months or more of
creditable coverage.
Paragraphs one and two of this subsection 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.
(c) For purposes of this section, "creditable coverage" means, with
respect to an individual, coverage of the individual under any of the
following:
(1) A group health plan;
(2) Health insurance coverage;
(3) Part A or B of title XVIII of the Social Security Act;
(4) Title XIX of the Social Security Act, other than coverage
consisting solely of benefits under section 1928;
(5) Chapter 55 of title 10, United States Code;
(6) A medical care program of the Indian Health Service or of a tribal
organization;
(7) A state health benefits risk pool;
(8) A health plan offered under chapter 89 of title 5, United States
Code;
(9) A public health plan (as defined in regulations);
(10) A health benefit plan under section 5(e) of the Peace Corps Act
(22 U.S.C. 2504(e)).
(d)(1) For purposes of applying the credit of such creditable
coverage, a corporation shall count a period of creditable coverage
without regard to the specific benefits covered during the period.
(2) Alternatively, a corporation may elect to count the period of
coverage based on coverage of benefits within each of several classes or
categories of benefits as specified in regulations. Such election shall
be made on a uniform basis for all subscribers, participants and
beneficiaries. Pursuant to such election a corporation shall count a
period of creditable coverage with respect to any class or category of
benefits if any level of benefits is covered within such class or
category. A corporation making such election shall prominently state in
any disclosure statement, and shall set forth in any contract or
certificate issued in connection with the coverage, that the corporation
has made such election. Such disclosure statement shall include a
description of the effect of the election with regard to the application
of creditable coverage.
(3) Notwithstanding the foregoing paragraph, for purposes of
determining the extent to which a pre-existing condition limitation has
been satisfied in a contract issued pursuant to section four thousand
three hundred twenty-one or four thousand three hundred twenty-two of
this article within thirty days of discontinuance of a class of health
maintenance organization direct payment contract for enrollees whose
contract was discontinued, a corporation shall credit the coverage of an
enrollee under a health maintenance organization direct payment contract
issued prior to January first, nineteen hundred ninety-six, without
regard to the specific benefits covered under the health maintenance
organization contract.
(4) With respect to an "eligible individual", as defined in section
2741(b) of the federal Public Health Service Act, 42 U.S.C. §
300gg-41(b), a corporation may not impose any pre-existing condition
exclusion in an individual health insurance contract. For all other
covered persons, the pre-existing condition crediting requirement of
subsection (a) of this section shall be applicable.
(e) For the purposes of this section the term "group health plan"
means an employee welfare benefit plan (as defined in section 3(1) of
the Employee Retirement Income Security Act of 1974) to the extent that
the plan provides medical care (including items and services paid for as
medical care) to employees or their dependents (as defined under the
terms of the plan) directly or through insurance, reimbursement or
otherwise.
(f) A corporation shall not impose any pre-existing condition
exclusion in an individual or group contract of hospital, medical,
surgical or prescription drug expense insurance.