Underwriting issues

When you apply for individual health insurance, the health insurance company uses a process called underwriting to look at your age, sex, and health history to decide whether it will cover you and how much it will cost to provide you coverage.

Q- Do all health insurance companies have the same underwriting guidelines for offering insurance?

No.  Each insurance company has its own underwriting guidelines, which are usually not made public.  However, insurance companies marketing and selling individual health insurance policies in California must file information with the Department of Insurance pertaining to their policies, procedures and underwriting guidelines for offering such insurance (Insurance Code Section 10113.95 which was added by Assembly Bill 356 in 2005).   We have summarized the information that companies have filed in the questions and answers and chart below.

What health conditions will cause a health insurance company to automatically refuse or deny my application for insurance?  

There are many medical conditions that may cause an insurance company to automatically deny or not approve your application.  These may include the following:

An insurance company may also automatically deny your application for the health conditions below.  There may be other health conditions that are not on this list.

Q - What will cause an insurance company to offer me insurance at a higher premium rate or limit the products or benefits I can get?

Insurance companies may offer you insurance at a higher premium and/or limit the products or benefits you can purchase if you had a health problem in the past but you have recovered or you have been without symptoms for some time.  Insurance companies will also do this for minor health problems that you had in the past or may currently have.  Insurance companies argue that these conditions pose a risk that it will cost more for your health claims than if you were completely healthy.  Each application and insurance company is different.  An insurance company may charge a higher premium or limit the products offered for the health conditions below.  There may be other health conditions and time frames that are not on this list.

Q - Will a health insurance company look at my height and weight when I apply for insurance?

Yes.  Insurance companies usually look at your height and weight when they decide to offer insurance.  They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese.  Some insurance companies use a measurement called the Body Mass Index (BMI) to decide.  If your BMI is above 39, most insurance companies will not offer you insurance.  If your BMI is 30-39, an insurance company may offer you insurance at a higher premium.  If you have health problems because of your weight, such as diabetes or heart disease, an insurance company may refuse to insure you, even if your BMI is under 30.
 

Q - Can a health insurance company look at my smoking and drinking history when I apply for insurance?

Yes.  Insurance companies may look at smoking and drinking history when they decide whether to offer insurance. 

Q - Does the state of Texas Mandate certain types of coverage?

SUMMARY OF TEXAS MANDATED BENEFITS, OFFERINGS AND COVERAGES

ACCIDENT & HEALTH INSURANCE
TEXAS MANDATED BENEFITS/OFFERS/COVERAGES
January 1, 1998
Download doc.

Mandated Benefits

ALZHEIMER'S DISEASE,

Biological Brain Disease and Serious Mental Illness -

Section 3.3826(a)(2)(A) & (B), Subchapter Y, Texas Administrative Code

 No long term care policy may exclude or limit coverage for covered services on the basis of a diagnosis of Alzheimer's disease or biologically-based brain disease/serious mental illness. Applicable to any individual or group long term care, home health or nursing home policy.
CHEMICAL DEPENDENCY - Article 3.51-9, Texas Insurance Code; Sections 3.8001 - 3.8022 Subchapter HH, Texas Administrative Code Benefits for the necessary care and treatment of chemical dependency must be provided on the same basis as other physical illnesses generally.

Benefits for treatment of chemical dependency may be limited to three separate series of treatments for each covered individual. The series of treatments must be in accordance with the standards adopted under 28 TAC §§3.8001 - 3.8022.

 Applicable to any group policy providing basic hospital, surgical or major medical expense benefits.
COMPLICATIONS OF PREGNANCY - Section 21.405, Subchapter E, Texas Administrative Code Benefits for complications of pregnancy must be provided on the same basis as for other illnesses. Applicable to any individual or group policy including major medical, hospital/medical/surgical, hospital indemnity, and disability coverages.
DIABETES - Article 21.53G, Texas Insurance Code Medical or surgical expense polices which provide benefits for treatment of diabetes and associated conditions must provide coverage to each qualified insured for diabetes equipment, diabetes supplies and diabetes self-management training programs. Applicable to any individual, group, blanket or franchise insurance policies that provide benefits for medical or surgical expenses. Not applicable to small employer health benefit plans.
EMERGENCY CARE - Article 3.70-3C, Section 5, Texas Insurance Code Reimbursement for the following emergency care services must be at the preferred provider level of benefits, if an insured cannot reasonably reach a preferred provider: (a) any medical screening examination or other evaluation required by state or federal law to be provided in the emergency facility of a hospital which is necessary to determine whether a medical emergency condition exists; (b) necessary emergency care services including treatment and stabilization of an emergency medical condition; and (c) services originating in a hospital emergency facility following treatment or stabilization of an emergency medical condition. Applicable to any insurance policy that contains preferred provider benefits.
GOVERNMENT HOSPITAL COVERAGE - Section 3.3040(d), Subchapter S, Texas Administrative Code Policies providing hospital confinement indemnity coverage may not contain provisions excluding coverage because of confinement in a hospital operated by the federal government. Applicable to any individual policy providing hospital indemnity coverage.
IMMUNIZATIONS - Article 21.53F, Texas Insurance Code Policies that provide benefits for a family member of the insured shall provide coverage for each covered child from birth through the date the child is six years old for (1) immunization against diphtheria; haemophilus influenzae type b; hepatitis B; measles; mumps; pertussis; polio; rubella; tetanus; and varicella; and (2) any other immunization that is required by law for the child. Immunizations may not be subject to a deductible, copayment or coinsurance requirement. Applicable to any individual, group, blanket or franchise insurance policies that provides benefits for medical or surgical expenses. Not applicable to small employer health benefit plans.
MAMMOGRAPHY - Article 3.70-2(H), Texas Insurance Code Annual screening by low-dose mammography for females 35 years old or older must be provided on the same basis as other radiological examinations. Applicable to any individual or group policy.
MASTECTOMY
  • Minimum Length of Stay following Mastectomy or Lymph Node Dissection - Article 21.52G, Texas Insurance Code
  • Reconstructive Surgery Incident to a Mastectomy - Article 21.53D, Texas Insurance Code

 

 Policies that provide benefits for the treatment of breast cancer must include coverage for inpatient care for an enrollee for a minimum of (a) 48 hours following a mastectomy and (b) 24 hours following a lymph node dissection for the treatment of breast cancer. A plan is not required to provide the minimum hours of coverage of inpatient care required if the enrollee and the enrolleeīs attending physician determine that a shorter period of inpatient care is appropriate.

Policies that provide coverage for mastectomy must provide coverage for breast reconstruction. The coverage may be subject to the same deductible or copayment applicable to mastectomy.

 

 Applicable to an individual, group, blanket or franchise insurance policy that provides benefits for medical or surgical expenses. Not applicable to small employer health benefit plans.

Applicable to an individual, group, blanket or franchise insurance policy that provides benefits for medical or surgical expenses, including cancer policies. Not applicable to small employer health benefit plans.
MATERNITY (Minimum Stay following Birth of a Child) - Article 21.53F, Texas Insurance Code Policies providing maternity benefits, including benefits for childbirth, must include coverage for inpatient care for a mother and her newborn child in a health care facility for a minimum of (a) 48 hours following uncomplicated vaginal delivery, and (b) 96 hours following uncomplicated C-section. Policies that provides in-home postdelivery care are not required to provide the minimum number of hours unless the inpatient care is determined to be medically necessary by the attending physician or is requested by the mother. Applies to individual, group, blanket of franchise insurance policies that provide benefits for medical or surgical expenses.
MENTAL/NERVOUS DISORDERS WITH DEMONSTRABLE ORGANIC DISEASE - Section 3.3057(d), Exhibit A, Subchapter S, Texas Administrative Code No individual policy may exclude mental, emotional or functional nervous disorders with demonstrable organic disease. Exclusion of mental/nervous disorders without demonstrable organic disease would be permitted in certain designated policies (not including disability income). Applicable to any individual policy (primarily major medical, hospital indemnity and hospital/medical/ surgical coverages.
ORAL CONTRACEPTIVES - Section 21.404, Subchapter E, Texas Administrative Code Benefits for oral contraceptives must be provided when ALL other prescription drugs are provided. Applicable to any individual or group policy providing coverage for prescription drugs.
OSTEOPOROSIS, DETECTION AND PREVENTION - Article 21.53C, Texas Insurance Code Policies that provide benefits for medical or surgical expenses incurred as a result of an accident or sickness must provide to qualified individuals coverage for medically accepted bone mass measurement to determine a personīs risk of osteoporosis and fractures associated with osteoporosis. Applicable to any group contract that provides benefits for medical or surgical expenses.
PHENYLKETONURIA (PKU) - Article 3.79, Texas Insurance Code Policies that provide benefits for prescription drugs must include formulas for treatment of PKU or other heritable diseases. Applicable to any group policy which provides coverage for prescription drugs.
PROSTATE TESTING - Articles 21.53F and 3.50-4, Sec. 18D, Texas Insurance Code
  • Policies that provides benefits for diagnostic medical procedures must provide coverage for each male enrolled in the plan for expenses incurred in conducting an annual medically recognized diagnostic examination for the detection of prostate cancer. Minimum benefits must include: (1) a physical examination for the detection of prostate cancer; and (2) a prostate-specific antigen test used for the detection of prostate cancer for each male enrolled in the plan who is at least 50 years of age and asymptomatic; or at least 40 years of age with a family history of prostate cancer or another prostate cancer risk factor - Article 21.53F.
  • A health benefit plan offered under the Texas Public School Employees Group Insurance Act must provide coverage for prostate specific antigen test for each male who is at least 50 years of age or at least 40 years of age with a family history of prostate cancer or other risk factor for medically accepted prostate specified antigen test - Article 3.50-4, Sec. 18D.
 Applies to an individual, group, blanket, or franchise insurance policy that provides benefits for medical or surgical expenses. Not applicable to small employer health benefit plans.

Applies to any health benefit plan offered under the Texas Public School Employees Group Insurance Act.
SERIOUS MENTAL ILLNESS - Articles 3.51-14, 3.50-2, 3.50-3 & 3.51-5A, Texas Insurance Code
  • A group health benefit plan (a) must provide coverage for 45 days of inpatient treatment, and 60 visits for outpatient treatment, including group and individual outpatient treatment coverage, for serious mental illness in each calendar year; (b) may NOT include a lifetime limit on the number of days of inpatient treatment or the number of outpatient visits covered under the plan; and (c) must include the same amount limits, deductibles, and coinsurance factors for serious mental illness as for physical illness - Article 3.51-14.
  • Benefits for serious mental illness must be provided as extensive as any other physical illness.
  • Texas State Employees Uniform Group Insurance Benefits Act - Article 3.50-2, Section 5(j)(2)
  • Texas State College and University Employees Uniform Insurance Benefits Act - Article 3.50-3, Section 4C(2)
  • Local Governments - Article 3.51-5A(a)(2)

NOTE: The definition of serious mental illness is not identical in all of the cited articles.

 Applies to any group health benefit plan that provides benefits for medical or surgical expenses.

Applicable to the specific governmental employee benefit plans referenced.
TELEMEDICINE - Article 21.53F, Texas Insurance Code Policies may not exclude a service from coverage solely because the service is provided through telemedicine and not provided through a face-to-face consultation. Benefits for a service provided through telemedicine may be made subject to a deductible, copayment, or coinsurance requirement; however, the deductible, copayment, or coinsurance may not exceed that required by the plan for the same service provided through a face-to-face consultation. Applies to an individual, group, blanket or franchise insurance policy that provides benefits for medical or surgical expenses. Not applicable to small employer health benefit plans.
TEMPOROMANDIBULAR JOINT (TMJ) - Article 21.53A, Texas Insurance Code Benefits for TMJ must be provided when benefits for other medically necessary diagnostic or surgical treatment of skeletal joints are provided. Applicable to a group health benefit plan that provides benefits for medical or surgical expenses. Not applicable to small employer health benefit plans.
TRANSPLANT DONOR COVERAGE - Section 3.3040(h), Subchapter S, Texas Administrative Code A policy providing a specific benefit for the recipient in a transplant operation shall also provide reimbursement of any medical expense of a live donor to the extent that the benefits remain and are available under the recipient's policy, after benefits for the recipient's own expenses have been paid. Applicable to any individual policy providing for transplant coverage.

 

Mandated Benefit Offers

ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE - Section 3.3040(g), Subchapter S, Texas Administrative Code When accidental death and dismemberment coverage is part of the insurance coverage offered under the contract, the insured shall have the option to include all eligible insureds under such coverage. Applicable to any individual policy providing accidental death and dismemberment coverage.
HOME HEALTH - Article 3.70-3B, Texas Insurance Code Unless rejected in writing by the group policyholder or negotiated for lesser benefits, benefits must provide services for skilled nursing; physical, occupational, speech, or respiratory therapy; home health aide; medical equipment and medical supplies other than drugs and medicines. Benefits must include at least 60 visits in any calendar year or in any continuous period of 12 months for each person covered under the policy. Applicable to group policies (primarily major medical and hospital/medical/ surgical coverages).
IN-VITRO FERTILIZATION - Article 3.51-6, Section 3A, Texas Insurance Code Unless rejected in writing by the group policyholder, benefits for in-vitro fertilization must be provided to the same extent as benefits provided for other pregnancy-related procedures subject to certain requirements. Applicable to any group policy providing coverage on an expense incurred basis (primarily major medical and hospital/medical/ surgical coverages).
MATERNITY BENEFITS - Section 21.404(6), Subchapter E, Texas Administrative Code No insurer may refuse to offer maternity coverage in an individual coverage if comparable family coverages would offer maternity coverage. Applicable to any individual policy (primarily major medical and hospital/medical/surgical coverages).
MENTAL HEALTH - Article 3.70-2(F), Texas Insurance Code The insurer must offer and the group policyholder shall have the right to reject benefits of mental or emotional illness. Applicable to any group accident and sickness policy (primarily major medical and hospital/medical/ surgical coverages).
SERIOUS MENTAL ILLNESS - Article 3.51-14, Texas Insurance Code Small employer carriers must offer to small employers coverage for serious mental illness that complies with the following: (a) coverage for 45 days of inpatient treatment, and 60 visits for outpatient treatment, including group and individual outpatient treatment coverage, for serious mental illness in each calendar year; (b) the coverage may NOT include a lifetime limit on the number of days of inpatient treatment or the number of outpatient visits covered under the plan; and (c) the coverage must include the same amount limits, deductibles, and coinsurance factors for serious mental illness as for physical illness. Applicable to small employer health benefit plans.
SPEECH AND HEARING - Article 3.70-2(G), Texas Insurance Code Unless rejected by the group policyholder or an alternative level of benefits is negotiated, benefits must be provided for the necessary care and treatment of loss or impairment of speech or hearing that are not less favorable than for physical illness generally. Applicable to any group policy providing coverage on an expense incurred basis (primarily major medical and hospital/medical/ surgical coverages).

Mandated Coverages

CHEMICAL DEPENDENCY TREATMENT FACILITY - Article 3.51-9, Texas Insurance Code Treatment of chemical dependency in a chemical dependency treatment facility must be covered as favorable as any other physical illness and must be provided on the same basis as treatment in a hospital. Applicable to group policies (primarily major medical and hospital/medical/surgical

coverages).
CONTINUATION    
  • CONTINUATION FOR CERTAIN DEPENDENTS - Article 3.51-6, Section 3B, Texas Insurance Code
 Continuation of coverage for certain dependents is required for a period of three years upon termination of coverage due to divorce from or retirement or death of the insured member. Applicable to any expense incurred group policy (primarily major medical and hospital/medical/surgical coverages).
  • CONTINUATION OF COVERAGE DURING LABOR DISPUTE - Article 3.51-8, Texas Insurance Code
 Continuation of coverage is required for a period of six months after cessation of work. Applicable to any group policy resulting in all or a portion of premiums being paid though a collective bargaining agreement - could include any coverages.
  • CONTINUATION OF COVERAGE UPON DIVORCE - Section 21.407, Subchapter E, Texas Administrative Code
 In individual policies, if a person loses coverage due to a change in marital status, that person shall be issued a policy which the insurer is then issuing which most nearly approximates the coverage in effect prior to the change in marital status. The policy will be issued without evidence of insurability and will have the same effective date and expiration date as the prior policy. Applicable to any individual policy.
  • CONTINUATION OF SPOUSE UPON DEATH OR AGE LIMIT OR OTHER OCCURRENCE - Sections 3.3052(b) & 3.3050(1), Subchapter S, Texas Administrative Code
 In the event of the insured's death, the spouse of the insured, if covered, shall become the insured in any guaranteed renewable, noncancellable, or limited guarantee of renewability individual policy. In policies covering both the insured and spouse, the age of the younger spouse will be used for fulfilling the age or duration requirements in guaranteed renewable, noncancellable, or limited guarantee of renewability policies. Applicable to any individual policy issued on a guaranteed renewable, noncancellable, or limited guarantee of renewability basis.
  • CONTINUATION/ CONVERSION - Article 3.51-6, 1(d)(3), Texas Insurance Code and Subchapter F, Texas Administrative Code
 Group policies delivered, issued for delivery or renewed on or after January 1, 1998, must provide continuation of coverage for a period of 6 months upon termination of coverage for any reason, except termination due to gross misconduct. Carriers may offer conversion coverage which complies with minimum benefit standards for conversion policies.

Through renewal on or after January 1, 1998, group policies must provide, at the insured's option, a conversion privilege or a continuation of coverage for a period of 6 months upon termination of coverage for any reason, except termination due to gross misconduct.

 Applicable to any expense incurred group policy (primarily major medical and hospital/medical/surgical coverages).

 
CRISIS STABILIZATION UNIT & RESIDENTIAL TREATMENT CENTER FOR CHILDREN AND ADOLESCENTS - Article 3.72, Texas Insurance Code A policy providing benefits for treatment of mental or emotional illness or disorder when confined in a hospital must include benefits for treatment in a crisis stabilization unit or residential treatment center for children and adolescents. For purposes of determining policy benefits and benefit maximums, each two days of treatment in the facility will be considered equal to one day of treatment in a hospital or inpatient program. Applicable to any group policy providing inpatient mental illness coverages (primarily major medical and hospital/medical/surgical coverages).
DEPENDENTS    
  • ADOPTED CHILDREN - Articles 3.51-6, Section 3D, 3.70-2(K), 26.21A and 26.84(b), Texas Insurance Code
 Policies providing coverage for the immediate family or children of an insured may not exclude or limit coverage for an adopted child. A child is considered to be a child of the insured, if the insured is a party in a suit in which the adoption of the child by the insured is sought.

Natural or adopted children of the insured may not be excluded from coverage based on residency with or financial responsibility of the group member or insured.

Natural or adopted children of the spouse of the insured may not be excluded from coverage based on financial responsibility, but are required to reside with the group member or person insured.

 Applicable to any individual or group accident or sickness policy.
  • CERTAIN GRANDCHILDREN - Articles 3.51-6, Section 3E, 3.70-2(L) & 3.70-2(M), Texas Insurance Code
 Policies that provide coverage for dependents must provide coverage for grandchildren if such grandchildren are dependents for federal income tax purposes.

 

 Applicable to any individual or group policy providing coverage for hospital, surgical or medical expense coverage.
  • CERTAIN STUDENTS - Article 21.24-2, Texas Insurance Code
 Policies that condition dependent coverage (for a child 21 years of age or older) on the childīs being a full-time student at an educational institution shall provide the coverage for an entire academic term during which the child begins as a full-time student and remains enrolled, regardless of whether the number of hours of instruction for which the child is enrolled is reduced to a level that changes the childīs academic status to less than that of a full-time student. Coverage will continue until the 10th day of instruction of the subsequent academic term; on which date the plan may terminate coverage of the child if the child does not return to full-time status before that date.

 

 Applies to a group, blanket or franchise health benefit plan that provides benefits for medical or surgical expenses. Not applicable to small employer health benefit plans.
  • MEDICAL SUPPORT FOR CHILDREN - Articles 3.96-1 thru 3.96-10, Texas Insurance Code and Sections 21.2001-21.2011, Subchapter K, Texas Administrative Code
 Policies that provide coverage for dependents must provide coverage for a child who must be provided medical support under an order issued under Section 1.01, Subchapter A, Chapter 231 of the Family Code. Applicable to any expense incurred individual or group policy that provides benefits for medical or surgical expenses.
  • MEDICAL SUPPORT FOR CHILDREN - Article 3.70-2(M)(1), Texas Insurance Code
 Policies that provide coverage for dependent children of a group member or a person insured under the policy must provide coverage for a child for whom the group member or insured must provide medical support under an order issued under Section 14.061, Family Code, or enforceable by a court in this state. Applicable to any individual and group accident or sickness policy.
  • MENTALLY/PHYSICALLY HANDICAPPED CHILDREN - Article 3.70-2(C), Texas Insurance Code; Section 3.3052(g), Subchapter S, Texas Administrative Code
 Continuation of coverage upon attainment of the limiting age is required for a child who is incapable of self-sustaining employment by reason of mental retardation or physical handicap and chiefly dependent upon the insured for support and maintenance. Applicable to any individual or group policy providing for dependent coverage.
  • NEWBORN CHILDREN - Articles 3.70-2(E), 26.21(n) and 26.84(a), Texas Insurance Code; Sections 3.3401- 3.3403, Subchapter U, Texas Administrative Code
 Policies that provide maternity coverage or dependent coverage must provide automatic coverage to a newborn child for congenital defects or abnormalities for the initial 31 days. Coverage must be continued beyond the 31 days if notification of the birth is given and any required premium paid within the 31-day period. Applicable to any individual or group policy providing accident and sickness coverage including major medical, hospital/medical/

surgical, and maternity.
EXTENSION OF BENEFITS    
  • UPON TERMINATION BY INSURER (INDIVIDUAL COVERAGE) - Section 3.3052(e), Subchapter S, Texas Administrative Code
 An extension of benefits is required upon termination of any individual policy by the insurer. Termination shall be without prejudice to any continuous loss which commenced while the policy was in force; however, may be based on the continuous total disability of the insured and limited to the duration of the policy benefit period, payment of the maximum benefit, or a period of not less than three months. Applicable to any individual policy.
  • FOR TOTALLY DISABLED PERSONS (GROUP COVERAGE) - Article 3.51-6A, Texas Insurance Code
 An extension of benefits is required upon termination of policy for totally disabled persons. In policies providing benefits for loss of time from work or specific indemnity during hospital confinement, benefits payable for that disability or confinement are not affected by the termination. In policies providing hospital or medical expense coverages, the extension must be provided at least for the period of the disability or 90 days, whichever is less. Applicable to any group policy (primarily major medical, hospital/ medical/surgical, disability income, hospital indemnity, accident medical expense coverages).
  • UPON ACCEPTANCE OF PREMIUM (INDIVIDUAL COVERAGE) - Section 3.3052(c), Subchapter S, Texas Administrative Code
 If an insurer accepts a premium for coverage extending beyond the date, age or event specified for termination of an insured family member, then coverage as to such person shall continue during the period for which an identifiable premium was accepted (unless due to a misstatement of age). Applicable to any individual policy.
  • PREGNANCY BENEFITS (INDIVIDUAL COVERAGE) - Section 3.3052(d), Subchapter S, Texas Administrative Code
 In the event of cancellation by the insurer or refusal to renew by the insurer of a policy providing pregnancy benefits, an extension of benefits is required for any pregnancy commencing while the policy is in force and for which benefits would have been payable had the policy continued in force. Applicable to any individual policy providing pregnancy benefits.
HIV, AIDS, OR HIV-RELATED ILLNESSES - Articles 3.51-6, Section 3C; 3.51-6D; 3.50-2, Section 5(j)(1); 3.50-3, Section 4C(1); and 3.51-5A(a)(1), Texas Insurance Code; Section 3.3057(d), Exhibit A, Subchapter S, Texas Administrative Code A policy may not exclude or deny coverage, and cancellation is prohibited for HIV, AIDS, or HIV-Related illness. Applicable to any individual or group policy (primarily major medical and hospital/medical/surgical coverages).
PODIATRIST CERTIFICATION - Article 21.52A, Texas Insurance Code A policy providing disability income benefits may not deny payment of those benefits when the disability is certified by a licensed podiatrist and the sickness or injury may be treated by the podiatrist under the scope of his license. Applicable to individual or group policies providing benefit for disability.
PRACTITIONERS - Articles 21.52, 21.52A, 3.70-2(B), 3.70-2(H),

3.70-3C, Texas Insurance Code

 Certain practitioners are required to be recognized when benefits are scheduled in the policy for which services can be performed within scope of licenses. Applicable to any group, individual, blanket, or franchise policy.
PREEXISTING CONDITIONS    
  • INDIVIDUAL COVERAGE - Article 3.70-1(H), Texas Insurance Code
 An individual health carrier must waive or reduce the preexisting condition time period as follows:

(a) The preexisting condition time period shall be waived for an individual who was continuously covered for an aggregate period of 18 months by creditable coverage that was in effect up to a date not more than 63 days before the effective date of the individual coverage provided the most recent creditable coverage was under a group health plan, governmental plan or church plan.

(b) If there has been more than a 63 day break between coverage, the preexisting time period of an individual health benefit plan shall be reduced by the time the individual was covered under creditable coverage during the 18 months preceding the effective date of coverage under the individual coverage provided the most recent creditable coverage was under a group health plan, governmental plan or church plan.

 Applies to individual hospital, medical or surgical coverages.
  • LONG TERM CARE COVERAGE - Section 3.3824 (c), Subchapter Y, Texas Administrative Code
 Replacing company shall waive any time periods applicable to preexisting conditions and probationary periods to the extent such time periods have been satisfied under the policy being replaced. Applicable to individual or group long term care policies.
  • MEDICARE SUPPLEMENT INSURANCE - Article 3.74, Section (8), Texas Insurance Code; Section 3.3306(1)(A), Texas Administrative Code
 Replacing company shall waive any time periods applicable to preexisting condition waiting periods, elimination periods, and probationary periods to the extent such time was spent under the original policy. Applicable to individual or group medicare supplement policies.
  • REPLACEMENT AND DISCONTINUANCE OF GROUP AND GROUP TYPE ACCIDENT AND HEALTH INSURANCE - Article 3.51-6A, Texas Insurance Code
 Benefits must be provided for preexisting conditions upon replacement of the master policy, but may provide the lesser of the benefits of the prior plan, or the benefits of the succeeding carrierīs plan determined without application of the preexisting conditions limitation. Applicable to any group policy (primarily major medical and hospital/medical/surgical coverages).
  • SMALL and LARGE EMPLOYER COVERAGE - Articles 26.49 (e) and (f) and 26.90(e) and (f), Texas Insurance Code
 A small or large small employer carrier must waive or reduce the preexisting condition time period as follows:

(a) The preexisting condition time period shall be waived for an individual who was continuously covered for an aggregate period of 12 months under creditable coverage that was in effect up to a date not more than 63 days before the effective date of coverage under the large or small employer health benefit plan.

(b) If there has been more than a 63 day break between coverage, the preexisting condition time period of a large or small employer health benefit plan shall be reduced by the time the individual was covered under creditable coverage during the 12 months preceding the effective date of coverage under the large or small employer health benefit plan.

 Applicable to large or small employer health benefit plans.
PSYCHIATRIC DAY TREATMENT FACILITY - Article 3.70-2(F), Texas Insurance Code A policy providing benefits for treatment of mental illness in a hospital must include benefits for treatment in a psychiatric day treatment facility. Determination of policy benefits and benefit maximums will consider each full day of treatment in a psychiatric day treatment facility equal to one-half day of treatment in a hospital or in-patient program. On rejection of mandated benefits the insurer shall offer and the policyholder can select an alternate level of benefits, but any negotiated benefits must include benefits for treatment in a psychiatric day treatment facility equal to at least one-half of that provided for treatment in hospital facilities. Applicable to any group policy providing mental illness coverage (primarily major medical, hospital/medical/surgical coverage).
PUBLIC INSTITUTIONS - Articles 3.70-2(D), 3.42B, Texas Insurance Code Policies may not exclude benefits when services are provided by tax supported institutions for which charges are made. Applicable to any group or individual policy.