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48.43.0122  <<  48.43.015 >>   48.43.017

RCW 48.43.015

Health benefit plans — Preexisting conditions.

(1) For a health benefit plan offered to a group, every health carrier shall reduce any preexisting condition exclusion, limitation, or waiting period in the group health plan in accordance with the provisions of section 2701 of the federal health insurance portability and accountability act of 1996 (42 U.S.C. Sec. 300gg).

     (2) For a health benefit plan offered to a group other than a small group:

     (a) If the individual applicant's immediately preceding health plan coverage terminated during the period beginning ninety days and ending sixty-four days before the date of application for the new plan and such coverage was similar and continuous for at least three months, then the carrier shall not impose a waiting period for coverage of preexisting conditions under the new health plan.

     (b) If the individual applicant's immediately preceding health plan coverage terminated during the period beginning ninety days and ending sixty-four days before the date of application for the new plan and such coverage was similar and continuous for less than three months, then the carrier shall credit the time covered under the immediately preceding health plan toward any preexisting condition waiting period under the new health plan.

     (c) For the purposes of this subsection, a preceding health plan includes an employer-provided self-funded health plan, the basic health plan's offering to health coverage tax credit eligible enrollees as established by chapter 192, Laws of 2004, and plans of the Washington state health insurance pool.

     (3) For a health benefit plan offered to a small group:

     (a) If the individual applicant's immediately preceding health plan coverage terminated during the period beginning ninety days and ending sixty-four days before the date of application for the new plan and such coverage was similar and continuous for at least nine months, then the carrier shall not impose a waiting period for coverage of preexisting conditions under the new health plan.

     (b) If the individual applicant's immediately preceding health plan coverage terminated during the period beginning ninety days and ending sixty-four days before the date of application for the new plan and such coverage was similar and continuous for less than nine months, then the carrier shall credit the time covered under the immediately preceding health plan toward any preexisting condition waiting period under the new health plan.

     (c) For the purpose of this subsection, a preceding health plan includes an employer-provided self-funded health plan, the basic health plan's offering to health coverage tax credit eligible enrollees as established by chapter 192, Laws of 2004, and plans of the Washington state health insurance pool.

     (4)(a) Except as provided in (b) of this subsection, for a health benefit plan offered to an individual, other than an individual to whom subsection (5) of this section applies, every health carrier shall credit any preexisting condition waiting period in that plan for a person who was enrolled at any time during the sixty-three day period immediately preceding the date of application for the new health plan in a group health benefit plan or an individual health benefit plan, other than a catastrophic health plan, and (i) the benefits under the previous plan provide equivalent or greater overall benefit coverage than that provided in the health benefit plan the individual seeks to purchase; or (ii) the person is seeking an individual health benefit plan due to his or her change of residence from one geographic area in Washington state to another geographic area in Washington state where his or her current health plan is not offered, if application for coverage is made within ninety days of relocation; or (iii) the person is seeking an individual health benefit plan: (A) Because a health care provider with whom he or she has an established care relationship and from whom he or she has received treatment within the past twelve months is no longer part of the carrier's provider network under his or her existing Washington individual health benefit plan; and (B) his or her health care provider is part of another carrier's provider network; and (C) application for a health benefit plan under that carrier's provider network individual coverage is made within ninety days of his or her provider leaving the previous carrier's provider network. The carrier must credit the period of coverage the person was continuously covered under the immediately preceding health plan toward the waiting period of the new health plan. For the purposes of this subsection (4), a preceding health plan includes an employer-provided self-funded health plan, the basic health plan's offering to health coverage tax credit eligible enrollees as established by chapter 192, Laws of 2004, and plans of the Washington state health insurance pool.

     (b) A carrier shall credit an applicant's period of coverage in his or her preceding catastrophic health plan toward any preexisting condition waiting period in the catastrophic health plan the applicant seeks to purchase if:

     (i) The preceding catastrophic health plan was discontinued by a carrier that is discontinuing all individual plan coverage by July 1, 2012;

     (ii) The applicant was enrolled in the previous catastrophic health plan during the sixty-three day period immediately preceding his or her application date for the new catastrophic health plan; and

     (iii) The benefits under the preceding catastrophic health plan provide equivalent or greater overall benefit coverage than that provided in the catastrophic health plan the applicant seeks to purchase.

     (5) Every health carrier shall waive any preexisting condition waiting period in its individual plans for a person who is an eligible individual as defined in section 2741(b) of the federal health insurance portability and accountability act of 1996 (42 U.S.C. Sec. 300gg-41(b)).

     (6) Subject to the provisions of subsections (1) through (5) of this section, nothing contained in this section requires a health carrier to amend a health plan to provide new benefits in its existing health plans. In addition, nothing in this section requires a carrier to waive benefit limitations not related to an individual or group's preexisting conditions or health history.

[2012 c 64 § 2; 2004 c 192 § 5; 2001 c 196 § 7; 2000 c 80 § 3; 2000 c 79 § 20; 1995 c 265 § 5.]

Notes:

     Effective date -- 2012 c 64: See note following RCW 48.43.018.

     Effective date -- 2004 c 192: See note following RCW 70.47.020.

     Effective date -- 2001 c 196: See note following RCW 48.20.025.

     Effective date -- Severability -- 2000 c 79: See notes following RCW 48.04.010.

     Captions not law -- Effective dates -- Savings -- Severability -- 1995 c 265: See notes following RCW 70.47.015.