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Texas Statutes (Last Updated: January 4, 2014) |
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INSURANCE CODE |
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Title 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES |
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Subtitle G. HEALTH COVERAGE AVAILABILITY |
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Chapter 1506. TEXAS HEALTH INSURANCE POOL |
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Subchapter D. POOL COVERAGE AND BENEFITS |
Sec. 1506.155. PREEXISTING CONDITIONS
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(a) Except as provided by this section and Section 1506.056, pool coverage excludes charges or expenses incurred before the first anniversary of the effective date of coverage with regard to any condition for which:
(1) the existence of symptoms would cause an ordinarily prudent person to seek diagnosis, care, or treatment within the six-month period preceding the effective date of coverage; or
(2) medical advice, care, or treatment was recommended or received during the six-month period preceding the effective date of coverage.
(a-1) Except as provided by Section 1506.056, pool coverage for an individual eligible pursuant to Section 1506.153(b) or (c) excludes charges or expenses incurred before the first anniversary of the effective date of coverage with regard to any condition for which:
(1) the existence of symptoms would cause an ordinarily prudent person to seek diagnosis, care, or treatment within the six-month period preceding the effective date of coverage; or
(2) medical advice, care, or treatment was recommended or received during the six-month period preceding the effective date of coverage.
(b) The exclusion provided by Subsection (a) does not apply to a federally defined eligible individual or an individual who:
(1) was continuously covered for a period of at least 12 months, excluding any waiting period, by creditable coverage that terminated not earlier than the 63rd day before the effective date of coverage under the pool; and
(2) applied for pool coverage not later than the 63rd day after the date the creditable coverage described by Subdivision (1) terminated.
(c) If an individual was covered by creditable coverage that was in effect at any time during the 12-month period preceding the effective date of the individual's coverage under the pool, the pool shall subtract from the exclusion period required under Subsection (a) the period that the individual was covered under that creditable coverage and any waiting period that applied before that creditable coverage became effective.
(c-1) If an individual eligible under Section 1506.153(b) was covered by creditable coverage at any time during the 12-month period immediately preceding the effective date of the individual's coverage under the pool, the pool shall subtract from the exclusion period required under Subsection (a-1) up to 180 days of:
(1) the period during which the individual was covered under the creditable coverage; and
(2) any waiting period that applied before the creditable coverage became effective.
(d) A preexisting condition provision may not be applied to an individual who has been certified as eligible for trade adjustment assistance or for pension benefit guaranty corporation assistance, as provided by the Trade Adjustment Assistance Reform Act of 2002 (Pub. L. No. 107-210), if the individual:
(1) was continuously covered by a health benefit plan for a period of three months before the individual's separation from employment; and
(2) applies for coverage from the pool not later than the 63rd day after the date on which the prior coverage was terminated.