Credit for Preexisting Conditions for Employer Health Benefit Plans (Portability)
Idaho Code, Title 41, Chapters 22 and 47, apply to employer health benefit plans*.
An employer health benefit plan may define a “preexisting condition” to mean 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 during the six months immediately preceding the effective date of coverage. Genetic information may not be considered a preexisting condition unless there is a diagnosis of the condition related to that information. A pregnancy on the effective date of coverage may not be considered a preexisting condition under an employer health benefit plan.
A health benefit plan may deny, exclude, or limit benefits for covered expenses incurred for preexisting conditions for 12 months following an individual’s effective date of coverage. Late enrollees may be excluded from coverage for the greater of 12 months or the 12-month preexisting condition exclusion period. If both an exclusion from coverage and a preexisting condition exclusion apply to a late enrollee, the combined period of time may not exceed 12 months from the date of enrollment.
However, if an individual was covered under qualifying previous coverage** within 63 days before his or her effective date under a new health benefit plan, the new plan must provide credit for the time insured under the qualifying previous coverage towards satisfaction of the 12-month preexisting condition exclusion or limitation. An employment waiting period does not count towards the 63-day gap in coverage.
* “Health benefit plan” means a hospital or medical policy or certificate.
“Health benefit plan” does not include a policy or certificate for specific disease, hospital confinement indemnity, accident-only, credit, dental, vision, Medicare supplement, long-term care, disability income insurance, student health benefits-only coverage issued as a supplement to liability insurance, workers’ compensation or similar insurance, automobile medical payment insurance, or nonrenewable short-term coverage issued for a period of 12 months or less. (§41-2221 and §41-4703)
** “Qualifying previous coverage” means benefits or coverage
1. Medicare or Medicaid, civilian health and medical program for uniformed services (CHAMPUS), the Indian health service program, a state health benefit risk pool, or any other similar publicly sponsored program; or
2. Any group or individual health insurance policy or health benefit arrangement whether or not subject to the state insurance laws, including coverage provided by a managed care organization, hospital or professional service corporation, or a fraternal benefit society.
(§41-2221 and §41-4703)