760 Ind. Admin. Code 1-68-4

Current through December 4, 2024

Section 760 IAC 1-68-4 - Coverage requirements

Authority: IC 27-1-34-9

Affected: IC 25-22.5; IC 25-29; IC 27-1-34

Sec. 4.

(a) A MEWA:

(1) may refuse to provide coverage to an employer employing fifty (50) or more employees in accordance with the MEWA's underwriting standards and criteria;

(2) shall accept or reject the entire group of individuals who meet the participation criteria and who choose coverage; and

(3) may exclude only those individuals who have declined coverage.

Denial by a MEWA of an application for coverage from an employer must be in writing and must state the reason or reasons for the denial.

(b) A MEWA must provide coverage to any employer that:

(1) meets the participating employer criteria; and

(2) employs two (2) to fifty (50) employees; unless the MEWA has adopted a resolution closing enrollment for a period of not less than two (2) years.

(c) Upon issuance of coverage to any employer, each MEWA shall provide coverage to the employees who meet the participation criteria established by the terms of the plan document without regard to an individual's health status related factors. The participation criteria may not be based on health status factors.

(d) The MEWA shall obtain a written waiver for each employee who:

(1) meets the participation criteria; and

(2) declines coverage under the MEWA.

The waiver must ensure that the employee was not induced or pressured into declining coverage because of the employee's or a dependent's health status.

(e) A MEWA may not provide coverage to an employer or the employees of an employer if the MEWA or an agent for the MEWA knows that the employer has induced or pressured:

(1) an employee who meets the participation criteria; or

(2) a dependent of the employee; to decline coverage because of that individual's health status.

(f) A MEWA may require an employer to meet minimum contribution or participation requirements as a condition of issuance and renewal in accordance with the terms of the MEWA's plan document. Those requirements shall be as follows:

(1) Stated in the plan document.

(2) Applied uniformly to each employer offered or issued coverage by the MEWA.

(g) The initial enrollment period for employees meeting the participation criteria must be at least thirty-one (31) days. If dependent coverage is offered, the dependent's open enrollment must also comply with this time period.

(h) A MEWA may establish a waiting period during which a new employee is not eligible for coverage in accordance with the plan document.

(i) A MEWA's plan document may not, by use of a rider or amendment applicable to a specific individual, limit or exclude coverage by type of illness, treatment, medical condition, or accident, except for preexisting conditions as follows:

(1) A preexisting condition provision in a MEWA may not apply to an expense incurred on or after the expiration of the twelve (12) months following the initial effective date of coverage of the participating employee or dependent. However, this time period may be extended to eighteen (18) months for a late enrollee as defined in the federal Health Insurance Portability and Accountability Act of 1996.

(2) A preexisting condition provision in a MEWA plan document may not apply to coverage for a disease or condition other than a disease or condition for which medical advice, diagnosis, care, or treatment was recommended or received during the six (6) months before the earlier of the:

(A) effective date of coverage; or

(B) first day of the waiting period.

(3) A MEWA shall not treat genetic information as a preexisting condition in the absence of a diagnosis of the condition related to the information.

(4) A MEWA shall not treat a pregnancy as a preexisting condition.

(5) A preexisting condition provision in a MEWA's plan document may not apply to an individual who was continuously covered for a period of twelve (12) months under creditable coverage that was in effect up to a date not more than sixty-three (63) days before the effective date of coverage under the health benefit plan, excluding any waiting period.

(6) In determining whether a preexisting condition provision applies to an individual covered by a MEWA's plan document, the MEWA shall credit the time the individual was covered under previous creditable coverage if the previous coverage was in effect at any time during the twelve (12) months preceding the effective date of coverage under the MEWA. If the previous coverage was issued under a health benefit plan, any waiting period shall also be credited to the preexisting condition provision period.

(7) This section does not preclude application of any waiting period applicable to all new participating employees under the health benefit plan in accordance with the terms of the MEWA's plan document.

(j) A MEWA shall provide that the benefits applicable to an individual or family member shall be payable with respect to a newly born or adopted child of an insured. The coverage shall:

(1) consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities; and

(2) include, but not be limited to, benefits for inpatient or outpatient expenses arising from medical and dental treatment (including orthodontic and oral surgery treatment) involved in the management of birth defects known as cleft lip and cleft palate.

If payment of a specific premium or fee is required to provide coverage for a child, the policy or contract may require that notification of the birth or adoption and payment of the required premium or fee must be furnished to the MEWA within thirty-one (31) days after the date of birth or adoption in order to have continuous coverage beyond the thirty-one (31) day period.

(k) Coverage offered by the MEWA shall comply with the following:

(1) The federal Women's Health and Cancer Rights Act.

(2) The federal Mental Health Parity Act.

(3) The federal Pregnancy Discrimination Act.

(l) The MEWA shall comply with the federal Health Insurance Portability and Accountability Act of 1996.

(m) The MEWA shall provide coverage for the following:

(1) The medically necessary treatment for diabetes, including medically necessary supplies and equipment as ordered in writing by a:

(A) physician licensed under IC 25-22.5; or

(B) podiatrist licensed under IC 25-29; subject to general provisions of the health benefit plan.

(2) At least one (1) prostate specific antigen test annually for an insured who is:

(A) at least fifty (50) years of age; or

(B) younger than fifty (50) years of age and at high risk for prostate cancer according to the most recent published guidelines of the American Cancer Society.

(3) Colorectal cancer examinations and laboratory tests for cancer for any nonsymptomatic insured, in accordance with the current American Cancer Society guidelines for a covered individual who is:

(A) fifty (50) years of age; or

(B) less than fifty (50) years of age and at high risk for colorectal cancer according to the most recent published guidelines of the American Cancer Society.

(n) A MEWA may not deny enrollment of a child of a covered individual because the child was born out of wedlock, the child is not claimed as a dependent on the parent's federal income tax return, or the child does not reside with the parent or in the MEWA's service area. Whenever a child of a noncustodial parent is eligible for coverage with or covered by the MEWA, the MEWA shall do the following:

(1) Provide any information to the custodial parent that is necessary for the child to obtain benefits through the MEWA.

(2) Permit the custodial parent, or the provider of medical services with the custodial parent's approval, to submit claims for covered services without the approval of the noncustodial parent.

(3) Make payments on insurance claims submitted under subdivision (2) directly to the:

(A) custodial parent;

(B) provider of the medical services; or

(C) office of Medicaid policy and planning.

(4) When a parent is required by a court or an administrative order to provide health coverage for a child and the parent is eligible for family health coverage with the MEWA, the MEWA must do all of the following:

(A) Permit the parent to enroll under the family coverage a child who is otherwise eligible for the coverage, without regard to any enrollment season restriction.

(B) Enroll a child under the family coverage upon application by:

(i) the child's custodial parent;

(ii) the office of Medicaid policy and planning; or

(iii) a Title IV-D agency whenever a noncustodial parent who is enrolled fails to apply for coverage of the child.

(C) The MEWA may not disenroll or eliminate coverage of a child who is otherwise eligible for coverage unless the MEWA is provided satisfactory written evidence that the:

(i) court order or administrative order is no longer in effect; or

(ii) child is or will be enrolled in comparable health coverage not later than the effective date of the disenrollment.

(o) If the MEWA coordinates benefits, the coordination of benefits provision must comply with 760 IAC 1-38.1.

760 IAC 1-68-4

Department of Insurance; 760 IAC 1-68-4; filed Apr 15, 2003, 2:20 p.m.: 26 IR 3038; filed Mar 7, 2006, 2:00 p.m.: 29 IR 2189; readopted filed Nov 24, 2009, 9:35 a.m.: 20091223-IR-760090791RFA

Readopted filed 11/20/2015, 9:25 a.m.: 20151216-IR-760150341RFA

Readopted filed 11/15/2021, 8:32 a.m.: 20211215-IR-760210419RFA