6.6.5079C    PREEXISTING CONDITIONS - PERMISSIBLE RESTRICTIONS IN SMALL GROUPS

(1) Eligible employees and their dependents making timely application must be accepted for coverage in a small employer's group health plan without any restrictions or limitations on coverage related to risk characteristics of the eligible individuals, except as provided in 33-22-1811(3) , MCA, and this rule.

(2) A preexisting condition exclusion must relate to a condition based on presence of a condition for which medical advice, diagnosis, care or treatment was recommended or received by the participant or beneficiary within the 6-month period ending on the enrollment date as defined in 33-22-140, MCA. Medical advice, diagnosis, care, or treatment may be taken into account only if it is recommended by, or received from, an individual licensed or similarly authorized to provide such services under state law and operating within the scope of practice authorized by state law. A negative diagnosis does not constitute medical advice, diagnosis, care, or treatment for purposes of determining whether there is a preexisting condition.

(3) A preexisting exclusion period may not extend more than the following periods of time:

(a) For an employee or dependent obtaining coverage within the initial period of eligibility, twelve months from the coverage effective date;

(b) For an employee or dependent obtaining coverage through a special enrollment period as set forth in 33-22-523, MCA, or an employee or dependent qualifying for a later enrollment period pursuant to 33-22-140(17) , MCA, twelve months from the coverage effective date;

(c) For an employee or dependent obtaining coverage as a late enrollee as defined in 33-22-140(17) , MCA, eighteen months from the enrollment date.

(4) Exclusionary riders are not permitted.

(5) A small group plan must not impose a preexisting exclusion more restrictive than those allowed in 33-22-514, MCA.

(6) The following may not be excluded as a preexisting condition:

(a) Genetic information in the absence of diagnosis of the condition related to the genetic information;

(b) Pregnancy;

(c) Adopted children as set forth in 33-22-130, MCA; and

(d) Newborns as set forth in 33-22-504, MCA.

(7) A health benefit plan must waive any time period permitted for a preexisting exclusion under this rule by applicable periods of creditable coverage as set forth in 33-22-1811(3) (b) and 33-22-141, MCA.

(8) Small group carriers are required to give prior notice of the imposition of a preexisting exclusion period as set forth in ARM 6.6.5079H(6) .

History: Sec. 33-22-1822, MCA; IMP, Sec. 33-22-1811, MCA; NEW, 1998 MAR p. 1698, Eff. 6/26/98.