New York Codes, Rules and Regulations
Title 11 - INSURANCE
Chapter III - Policy and Certificate Provisions
Subchapter A - Life, Accident and Health Insurance
Part 52 - Minimum Standards For Form, Content And Sale Of Health Insurance, Including Standards Of Full And Fair Disclosure
Section 52.20 - Rules relating to preexisting condition provisions and crediting requirements in policies which provide hospital, surgical or medical expense coverage

(1) Individual health insurance policies and group and blanket accident and health insurance policies which provide hospital, surgical or medical expense coverage may include preexisting condition provisions which are at least as favorable to the covered person as those set forth in this section.

(2) The requirements of this section shall not be applicable to any individual, group or blanket insurance policy in relation to its provision of "excepted benefits" as defined in section 2791(c) of the Federal Public Health Service Act (42 U.S.C. section 300gg-91 [c]) and meeting the requirements for exception as set forth in section 2721(c) or (d) of the Federal Public Health Service Act (42 U.S.C. section 300gg-21 [c] and [d]) or section 2763(a) or (b) of the Federal Public Health Service Act (42 U.S.C. section 300gg-63 [a] and [b]). However, this exemption shall not be applicable to any policy providing hospital or surgical indemnity benefits with specific dollar amounts that exceed the amounts required to meet the definitions of basic hospital and basic medical insurance in sections 52.5 and 52.6 of this Part.

(1) No preexisting condition provision shall exclude coverage for a period in excess of 12 months following the enrollment date for a 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.

(2) For purposes of this section, enrollment date has the meaning prescribed in sections 3232 and 4318 of the Insurance Law.

(3) 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.

(4) No preexisting condition provision shall exclude coverage in the case of:

(5) With respect to an "eligible individual" as defined in section 2741(b) of the Federal Public Health Service Act, 42 U.S.C. section 300 gg - 41(b), an insurer shall not impose any preexisting condition exclusion in an individual health insurance policy.

(6)

(7) Individual direct payment policies issued pursuant to sections 4321 and 4322 of the Insurance Law must include a preexisting condition provision that complies with this section.

(1) In applying a preexisting condition provision to a covered person, the policy 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 63 days prior to the enrollment date of the new coverage. For purposes of this section, creditable coverage has the meaning prescribed in sections 3232 and 4318 of the Insurance Law.

(2) Crediting shall not be required when the previous coverage was for insurance as described in paragraph (a)(2) of this section.

(3) In applying the credit an insurer shall count a period of creditable coverage without regard to the specific benefits covered during the period of creditable coverage.

(4) As an alternative to the method described in paragraph (3) of this section, an insurer may elect to count the period of creditable coverage based on coverage of benefits within each of several classes or categories of benefits.

(5) The election of an alternative method of counting the period of creditable coverage shall be made on a uniform basis for all insureds, subscribers, participants and beneficiaries. When such election is made, an insurer 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.

(6) An insurer making an election to credit by alternative method shall prominently so state in a disclosure statement, and shall set forth in any policy or certificate issued in connection with the coverage, that the insurer has made such election. Details of the alternative method of counting creditable coverage shall be set forth in the policy and certificate. The disclosure statement shall include a description of the effect of the alternative method election with regard to the application of creditable coverage.

(7) In the case of previous health maintenance organization coverage, any specified affiliation period prior to such previous coverage becoming effective shall also be credited provided that the previous health maintenance organization coverage was continuous to a date not more than 63 days prior to the enrollment date of the new coverage.

(8) If a health maintenance organization elects to use a specified affiliation period pursuant to paragraph (b)(6) of this section, such affiliation period shall be reduced by the time the covered person was previously covered under creditable coverage which was continuous to a date not more than 63 days prior to the enrollment date.