                                 CODE OF VIRGINIA

LIMITATION ON PREEXISTING CONDITION EXCLUSION PERIOD (§ 38.2-3432.3)

A. Subject to subsection B, a health insurer offering health insurance coverage
may, with respect to a participant or beneficiary, impose a preexisting
limitation only if:

   1. For group health insurance coverage, such exclusion relates 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 individual health insurance coverage, such exclusion relates to a
   condition that, during a 12-month period immediately preceding the effective
   date of coverage, had manifested itself in such a manner as would cause an
   ordinarily prudent person to seek diagnosis, care, or treatment, or for which
   medical advice, diagnosis, care or treatment was recommended or received
   within 12 months immediately preceding the effective date of coverage;

   3. Such exclusion extends for a period of not more than 12 months (or 12
   months in the case of a late enrollee) after the enrollment date; and

   4. The period of any such preexisting condition exclusion is reduced by the
   aggregate of the periods of creditable coverage, if any, applicable to the
   participant or beneficiary as of the enrollment date.

B. Exceptions:

   1. Subject to subdivision 4, a health insurance issuer offering health
   insurance coverage may not impose any preexisting condition exclusion in the
   case of an individual who, as of the last day of the 30-day period beginning
   with the date of birth, is covered under creditable coverage;

   2. Subject to subdivision 4, a health insurance issuer offering health
   insurance coverage may not impose any preexisting condition exclusion in the
   case of a child who is adopted or placed for adoption before attaining 18
   years of age and who, as of the last day of the 30-day period beginning on the
   date of the adoption or placement for adoption, is covered under creditable
   coverage. The previous sentence shall not apply to coverage before the date of
   such adoption or placement for adoption;

   3. A health insurance issuer offering health insurance coverage may not impose
   any preexisting condition exclusion relating to pregnancy as a preexisting
   condition, except in the case of individual health insurance coverage for a
   person who is not considered an eligible individual, as defined in &#xA7;
   38.2-3430.2, in which case the health insurance issuer may impose a
   preexisting condition exclusion for a pregnancy existing on the effective date
   of coverage;

   4. Subdivisions 1 and 2 shall no longer apply to an individual after the end
   of the first 63-day period during all of which the individual was not covered
   under any creditable coverage; and

   5. Subdivision A 4 shall not apply to health insurance coverage offered in the
   individual market on a &#8220;guarantee issue&#8221; basis without regard to
   health status including policies, contracts, certificates, or evidences of
   coverage issued through a bona fide association or to students through school
   sponsored programs at an institution of higher education unless the person is
   an eligible individual as defined in &#xA7; 38.2-3430.2.

C. A period of creditable coverage shall not be counted, with respect to
enrollment of an individual under a health benefit plan, if, after such period
and before the enrollment date, there was a 63-day period during all of which
the individual was not covered under any creditable coverage.

D. For purposes of subdivision B 4 and subsection C, any period that an
individual is in a waiting period for any coverage under a group health plan (or
for group health insurance coverage) or is in an affiliation period shall not be
taken into account in determining the continuous period under subsection C.

E. Methods of crediting coverage:

   1. Except as otherwise provided under subdivision 2, a health insurance issuer
   offering group health coverage shall count a period of creditable coverage
   without regard to the specific benefits covered during the period;

   2. A health insurance issuer offering group health insurance coverage may
   elect to count a period of creditable coverage based on coverage of benefits
   within each of several classes or categories of benefits rather than as
   provided under subdivision 1. Such election shall be made on a uniform basis
   for all participants and beneficiaries. Under such election a health insurance
   issuer 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;

   3. In the case of an election with respect to a group plan under subdivision 2
   (whether or not health insurance coverage is provided in connection with such
   plan), the plan shall (i) prominently state in any disclosure statements
   concerning the plan, and state to each enrollee at the time of enrollment
   under the plan, that the plan has made such election and (ii) include in such
   statements a description of the effect of this election; and

   4. In the case of an election under subdivision 2 with respect to health
   insurance coverage offered by a health insurance issuer in the small or large
   group market, the health insurance issuer shall (i) prominently state in any
   disclosure statements concerning the coverage, and to each employer at the
   time of the offer or sale of the coverage, that the health insurance issuer
   has made such election and (ii) include in such statements a description of
   the effect of such election.

F. Periods of creditable coverage with respect to an individual shall be
established through presentation of certifications described in subsection G or
in such other manner as may be specified in federal regulations.

G. A health insurance issuer offering group health insurance coverage shall
provide for certification of the period of creditable coverage:

   1. At the time an individual ceases to be covered under the plan or otherwise
   becomes covered under a COBRA continuation provision;

   2. In the case of an individual becoming covered under a COBRA continuation
   provision, at the time the individual ceases to be covered under such
   provision; and

   3. At the request, or on behalf of, an individual made not later than 24
   months after the date of cessation of the coverage described in subdivision 1
   or 2, whichever is later. The certification under subdivision 1 may be
   provided, to the extent practicable, at a time consistent with notices
   required under any applicable COBRA continuation provision.

H. To the extent that medical care under a group health plan consists of group
health insurance coverage, the plan is deemed to have satisfied the
certification requirement under this section if the health insurance issuer
offering the coverage provides for such certification in accordance with this
section.

I. In the case of an election described in subdivision E 2 by a health insurance
issuer, if the health insurance issuer enrolls an individual for coverage under
the plan and the individual provides a certification of coverage of the
individual under subsection F:

   1. Upon request of such health insurance issuer, the entity which issued the
   certification provided by the individual shall promptly disclose to such
   requesting group insurance issuer information on coverage of classes and
   categories of health benefits available under such entity&#8217;s plan or
   coverage; and

   2. Such entity may charge the requesting health insurance issuer for the
   reasonable cost of disclosing such information.

J. A health insurance issuer offering group health insurance coverage shall
permit an employee who is eligible, but not enrolled, for coverage under the
terms of the plan (or a dependent of such an employee if the dependent is
eligible, but not enrolled, for coverage under such terms) to enroll for
coverage under the terms of the plan if each of the following conditions is met:

   1. The employee or dependent was covered under a group health plan or had
   health insurance coverage at the time coverage was previously offered to the
   employee or dependent;

   2. The employee stated in writing at such time that coverage under a group
   health plan or health insurance coverage was the reason for declining
   enrollment, but only if the plan sponsor or health insurance issuer (if
   applicable) required such a statement at such time and provided the employee
   with notice of such requirement (and the consequences of such requirement) at
   such time;

   3. The employee&#8217;s or dependent&#8217;s coverage described in subdivision
   1 (i) was under a COBRA continuation provision and the coverage under such
   provision was exhausted or (ii) was not under such a provision and either the
   coverage was terminated as a result of loss of eligibility for the coverage
   (including as a result of legal separation, divorce, death, termination of
   employment, or reduction in the number of hours of employment) or employer
   contributions towards such coverage were terminated; and

   4. Under the terms of the plan, the employee requests such enrollment not
   later than 30 days after the date of exhaustion of coverage described in
   clause (i) of subdivision 3 or termination of coverage or employer
   contribution described in clause (ii) of subdivision 3.

K. If (i) a health insurance issuer makes coverage available with respect to a
dependent of an individual; (ii) the individual is a participant under the plan
(or has met any waiting period applicable to becoming a participant under the
plan and is eligible to be enrolled under the plan but for a failure to enroll
during a previous enrollment period); and (iii) a person becomes such a
dependent of the individual through marriage, birth, or adoption or placement
for adoption, the health insurance issuer shall provide for a dependent special
enrollment period described in subsection L during which the person (or, if not
otherwise enrolled, the individual) may also be enrolled under the plan as a
dependent of the individual, and in the case of the birth or adoption of a
child, the spouse of the individual may also be enrolled as a dependent of the
individual if such spouse is otherwise eligible for coverage.

L. A dependent special enrollment period under this subsection shall be a period
of not less than 30 days and shall begin on the later of:

   1. The date dependent coverage is made available; or

   2. The date of the marriage, birth, or adoption or placement for adoption (as
   the case may be) described in subsection K.

M. If an individual seeks to enroll a dependent during the first 30 days of such
a dependent special enrollment period, the coverage of the dependent shall
become effective:

   1. In the case of marriage, not later than the first day of the first month
   beginning after the date the completed request for enrollment is received;

   2. In the case of a dependent&#8217;s birth, as of the date of such birth; or

   3. In the case of a dependent&#8217;s adoption or placement for adoption, the
   date of such adoption or placement for adoption.

N. A late enrollee may be excluded from coverage for up to 12 months or may have
a preexisting condition limitation apply for up to 12 months; however, in no
case shall a late enrollee be excluded from some or all coverage for more than
12 months. An eligible employee or dependent shall not be considered a late
enrollee if all of the conditions set forth below in subdivisions 1 through 4
are met or one of the conditions set forth below in subdivision 5 or 6 is met:

   1. The individual was covered under a public or private health benefit plan at
   the time the individual was eligible to enroll.

   2. The individual certified at the time of initial enrollment that coverage
   under another health benefit plan was the reason for declining enrollment.

   3. The individual has lost coverage under a public or private health benefit
   plan as a result of termination of employment or employment status
   eligibility, the termination of the other plan&#8217;s entire group coverage,
   death of a spouse, or divorce.

   4. The individual requests enrollment within 30 days after termination of
   coverage provided under a public or private health benefit plan.

   5. The individual is employed by a small employer that offers multiple health
   benefit plans and the individual elects a different plan offered by that small
   employer during an open enrollment period.

   6. A court has ordered that coverage be provided for a spouse or minor child
   under a covered employee&#8217;s health benefit plan, the minor is eligible
   for coverage and is a dependent, and the request for enrollment is made within
   30 days after issuance of such court order.
   				However, such individual may be considered a late enrollee for benefit
   riders or enhanced coverage levels not covered under the enrollee&#8217;s
   prior plan.

O. The provisions of this section shall not apply in any instance in which the
provisions of this section are inconsistent or in conflict with a provision of
Article 6 (&#xA7; 38.2-3438 et seq.) of Chapter 34.

HISTORY: 1997, cc. 807, 913; 1998, c. 24; 1999, c. 1004; 2000, c. 136; 2003, c.
221; 2011, c. 882; 2013, cc. 136, 210.