California Code of Regulations
Title 10 - Investment
Chapter 5.5 - Major Risk Medical Insurance Board
Article 3 - Minimum Scope of Benefits
Section 2698.303 - Pre-Existing Condition Exclusion and Post-Enrollment Waiting Period

Universal Citation: 10 CA Code of Regs 2698.303

Current through Register 2024 Notice Reg. No. 38, September 20, 2024

(a) Unless a waiver is granted pursuant to subsection (c), subscribers and enrolled dependents who enroll in a health maintenance organization participating health plan shall be subject to a post-enrollment waiting period. The post-enrollment waiting period shall apply to all subscribers and enrolled dependents. Subscribers shall not be required to pay subscriber contributions during the waiting period. The post-enrollment waiting period shall be 3 months unless reduced pursuant to subsection (d).

(b) Unless a waiver is granted pursuant to subsection (c), subscribers and enrolled dependents who enroll in a fee-for-service participating health plan shall be subject to a pre-existing condition exclusion period. During the pre-existing condition exclusion period no benefits or services related to a pre-existing condition shall be covered. Subscribers shall be required to pay subscriber contributions during the pre-existing condition exclusion period. The pre-existing condition exclusion period shall be 3 months unless reduced pursuant to subsection (d).

(c) Waivers or partial waivers to the post-enrollment waiting period or pre-existing condition exclusion period shall be granted for each individual subscriber or enrolled dependent providing any of the following criteria are met:

(1) The subscriber and/or enrolled dependent applies for the program within 180 days of the termination of prior creditable coverage, and such coverage was terminated due to:
(A) a loss of employment,

(B) the employer stopped offering or sponsoring health coverage, or

(C) the employer stopped making contributions towards health coverage.

(2) If the subscriber or enrolled dependent applies for the program within 63 days of the termination of prior creditable coverage and such coverage was terminated due to reasons other than:
(A) the criteria in (c)(1)(A), (B), or (C) of this section;

(B) non-payment of premiums; or

(C) fraud.

(3) The subscriber or dependent(s) who had previously received coverage under a similar program in another state within the last 12 months, shall be granted a full waiver of 3 months.

(4) A dependent age 18 and under who enrolled pursuant to section 2698.206 shall be granted a full waiver of 3 months.

(5) The subscriber who was on the program waiting list in accordance with Section 2698.202 for 180 days or longer shall be granted a full waiver of 3 months. A full waiver of 3 months shall also be granted for any dependents enrolled at the same time as the subscriber.

(d) Waivers or partial waivers to the post-enrollment waiting period or pre-existing condition exclusion period for individuals meeting the requirements of (c)(1) or (c)(2) of this section shall be calculated as follows:

(1) If the prior creditable coverage was for 3 consecutive months or more, a full waiver of 3 consecutive months shall be granted.

(2) If the prior creditable coverage was for 2 consecutive months, a partial waiver of 2 consecutive months shall be granted.

(3) If the prior creditable coverage was for 1 month, a partial waiver of 1 month shall be granted.

(4) If the prior creditable coverage was for less than 1 month, no waiver shall be granted.

(e) The program shall fully explain to applicants the type of health care coverage offered by each participating health plan, including the applicable waiting/exclusion periods specified in this section.

1. New section filed 12-20-90 as an emergency; operative 12-20-90 (Register 91, No. 11). A Certificate of Compliance must be transmitted to OAL by 4-19-91 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 12-20-90 order transmitted to OAL on 4-18-91 and filed 5-17-91 (Register 91, No. 27).
3. Amendment of subsection (c)(4) filed 7-10-91 as an emergency; operative 7-10-91 (Register 91, No. 43). A Certificate of Compliance must be transmitted to OAL by 11-7-91 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 7-10-91 order including amendment of subsection (c)(4) transmitted to OAL 10-23-91 and filed 11-21-91 (Register 92, No. 8).
5. New subsection (c)(5) filed 3-10-92 as an emergency; operative 3-10-92 (Register 92, No 19). A Certificate of Compliance must be transmitted to OAL 7-8-92 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 3-10-92 order transmitted to OAL 6-30-92 and filed 7-29-92 (Register 92, No. 31).
7. Amendment of section and NOTE filed 5-19-95; operative 6-19-95 (Register 95, No. 20).
8. Amendment of section heading and section filed 8-4-2003 as an emergency; operative 8-4-2003 (Register 2003, No. 32). Amendments to remain in effect for 180 days pursuant to section 21, chapter 794, Statutes of 2002 (AB 1401). A Certificate of Compliance must be transmitted to OAL by 2-2-2004 or emergency language will be repealed by operation of law on the following day.
9. Certificate of Compliance as to 8-4-2003 order transmitted to OAL 1-23-2004 and filed 3-1-2004 (Register 2004, No. 10).

Note: Authority cited: Sections 12711 and 12712, Insurance Code. Reference: Section 12726, Insurance Code.

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