Large Group Market Requirements

Large Group Market Requirements A. Prohibition Against Discrimination Within Large Groups At 42 U.S.C. § 300gg-1, and at 45 C.F.R. § 146.121, HIPAA bars health insurance issuers that offer coverage in the large group market from establishing rules for eligibility that are based on health status-related factors, and from requiring individuals within large groups to pay a higher premium or contribution than would a similarly situated individual, based on a health status-related factor. Every health insurance issuer which offers coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg-1 and 45 C.F.R. § 146.121. B. Preexisting Condition Exclusions 1. Miss. Code Ann. § 83-9-49 (1) (Rev. 1999) permits health insurance issuers in the large group market to apply preexisting condition limitations which do not contain a definition of a preexisting condition more restrictive than the following: a. A condition that would have caused an ordinary prudent person to seek medical advice, diagnosis, care or treatment during the six (6) months immediately preceding the effective date of coverage; b. A condition for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) months immediately preceding the effective date of coverage. At 42 U.S.C. § 300gg(a) and 45 C.F.R. § 146.111(a)(1)(i), HIPAA provides that a preexisting condition exclusion in a policy issued in the large group market can only relate to a condition, regardless of its cause, for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the enrollment date. Unlike Miss. Code Ann. § 83-9-49 (1) (b) (Rev. 1999), there is no provision under HIPAA allowing a health insurance issuer in the large group market to apply a preexisting condition limitation for a condition that would have caused an ordinary prudent person to seek medical advice, diagnosis, care or treatment during the six (6) months immediately preceding the effective date of coverage. Every health insurance issuer which offers coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg(a) and 45 C.F.R. § 146.111(a)(1)(i), which limit the definition of a preexisting condition 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 6-month period ending on the enrollment date." 2. At 42 U.S.C. § 300gg(d), and at 45 C.F.R. § 146.111(b), HIPAA bars health insurance issuers offering coverage in the large group market from applying preexisting conditions to certain newborns, certain adopted children and to the condition of pregnancy. Every health insurance issuer which offers coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg(d) and 45 C.F.R. § 146.111(b). 3. At 42 U.S.C. § 300gg(b)(1)(B), HIPAA bars health insurance issuers offering coverage in the large group market from applying preexisting condition limitations to genetic information in the absence of a diagnosis of the condition related to such information. Every health insurance issuer which offers coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg(b)(1)(B). C. Rules Relating To Crediting Previous Coverage At 42 U.S.C. § 300gg(c), and at 45 C.F.R. § 146.113, HIPAA requires health insurance issuers offering coverage in the large group market to reduce or eliminate the duration of any preexisting condition exclusion by the duration of the person's creditable coverage. Coverage is creditable if it ended within 63 days of the new coverage. The duration of consecutive creditable coverages are added to calculate the total amount of creditable coverage, as long as the break between such coverages does not exceed 63 days. Every health insurance issuer which offers coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg(c) and 45 C.F.R. § 146.113. D. Certificates Of Creditable Coverage At 42 U.S.C. § 300gg (e), and at 45 C.F.R. § 146.115, HIPAA requires health insurance issuers in the large group market to provide certificates of creditable coverage under a variety of circumstances when a person's coverage terminates. Every health insurance issuer providing coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg (e) and 45 C.F.R. § 146.115. E. Guaranteed Renewability Of Coverage In The Large Group Market At 42 U.S.C. § 300gg-12, and at 45 C.F.R. § 146.152, HIPAA requires health insurance issuers in the large group market to offer guaranteed renewal of policies, with some specific exceptions. These provisions also set forth certain requirements for the uniform termination of coverage in the large group market. Every health insurance issuer which offers coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg-12 and 45 C.F.R. § 146.152. F. Special Enrollment Periods At 42 U.S.C. § 300gg(f), and at 45 C.F.R. § 146.117, HIPAA requires health insurance issuers which offer coverage in the large group market to offer eligible employees and dependents special enrollment rights upon the loss of certain other coverage. These provisions also require health insurance issuers in the large group market to offer special enrollment rights when a new dependent becomes eligible through marriage, birth or adoption. Every health insurance issuer which offers coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg (f) and 45 C.F.R. § 146.117. G. Health Maintenance Organization Affiliation Period At 42 U.S.C. § 300gg (g), and at 45 C.F.R. § 146.119, HIPAA permits health maintenance organizations ("HMOs") which offer coverage in the large group market to applyaffiliation periods in the large group market only if the HMOs do not apply any preexisting condition exclusions, the period is applied uniformly without regard to health status-related factors, and the period does not exceed 2 months, or three months for late enrollees. Every HMO which offers coverage in the large group market in the State of Mississippi shall fully comply with the provisions of 42 U.S.C. § 300gg (g) and 45 C.F.R. § 146.119.