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Federal Register / Vol. 62, No. 67 / Tuesday, April 8, 1997 / Rules and Regulations

(B) A special enrollment date for the

individual. If an individual ceases to be

eligible for coverage under the plan by

terminating employment, and

subsequently becomes eligible for

coverage under the plan by resuming

employment, only eligibility during the

individual’s most recent period of

employment is taken into account in

determining whether the individual is a

late enrollee under the plan with respect

to the most recent period of coverage.

Similar rules apply if an individual

again becomes eligible for coverage

following a suspension of coverage that

applied generally under the plan.

(v) Examples. The following examples

illustrate the requirements of this

paragraph (a)(2):

Example 1: (i) Employee F first becomes

eligible to be covered by Employer W’s group

health plan on January 1, 1999, but elects not

to enroll in the plan until April 1, 1999. April

1, 1999 is not a special enrollment date for

F.

(ii) In this Example, F would be a late

enrollee with respect to F’s coverage that

became effective under the plan on April 1,

1999.

Example 2: (i) Same as Example 1, except

that F does not enroll in the plan on April

1, 1999 and terminates employment with

Employer W on July 1, 1999, without having

had any health insurance coverage under the

plan. F is rehired by Employer W on January

1, 2000 and is eligible for and elects coverage

under Employer W’s plan effective on

January 1, 2000.

(ii) In this Example, F would not be a late

enrollee with respect to F’s coverage that

became effective on January 1, 2000.

(b) Exceptions pertaining to

preexisting condition exclusions—(1)

Newborns—(i) General rule. Subject to

paragraph (b)(3) of this section, a group

health plan, and a health insurance

issuer offering group health insurance

coverage, may not impose any

preexisting condition exclusion with

regard to a child who, as of the last day

of the 30-day period beginning with the

date of birth, is covered under any

creditable coverage. Accordingly, if a

newborn is enrolled in a group health

plan (or other creditable coverage)

within 30 days after birth and

subsequently enrolls in another group

health plan without a significant break

in coverage, the other plan may not

impose any preexisting condition

exclusion with regard to the child.

(ii) Example. The following example

illustrates the requirements of this

paragraph (b)(1).

Example: (i) Seven months after

enrollment in Employer W’s group health

plan, Individual E has a child born with a

birth defect. Because the child is enrolled in

Employer W’s plan within 30 days of birth,

no preexisting condition exclusion may be

imposed with respect to the child under

Employer W’s plan. Three months after the

child’s birth, E commences employment with

Employer X and enrolls with the child in

Employer X’s plan within 45 days of leaving

Employer W’s plan. Employer X’s plan

imposes a 12-month exclusion for any

preexisting condition.

(ii) In this Example, Employer X’s plan

may not impose any preexisting condition

exclusion with respect to E’s child because

the child was covered within 30 days of birth

and had no significant break in coverage.

This result applies regardless of whether E’s

child is included in the certificate of

creditable coverage provided to E by

Employer W indicating 300 days of

dependent coverage or receives a separate

certificate indicating 90 days of coverage.

Employer X’s plan may impose a preexisting

condition exclusion with respect to E for up

to 2 months for any preexisting condition of

E for which medical advice, diagnosis, care,

or treatment was recommended or received

by E within the 6-month period ending on E’s

enrollment date in Employer X’s plan.

(2) Adopted Children. Subject to

paragraph (b)(3) of this section, a group

health plan, and a health insurance

issuer offering group 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.

This rule does not apply to coverage

before the date of such adoption or

placement for adoption.

(3) Break in coverage. Paragraphs

(b)(1) and (b)(2) of this section no longer

apply to a child after a significant break

in coverage.

(4) Pregnancy. A group health plan,

and a health insurance issuer offering

group health insurance coverage, may

not impose a preexisting condition

exclusion relating to pregnancy as a

preexisting condition.

(5) Special enrollment dates. For

special enrollment dates relating to new

dependents, see § 146.117(b).

(c) Notice of plan’s preexisting

condition exclusion. A group health

plan, and health insurance issuer

offering group health insurance under

the plan, may not impose a preexisting

condition exclusion with respect to a

participant or dependent of the

participant before notifying the

participant, in writing, of the existence

and terms of any preexisting condition

exclusion under the plan and of the

rights of individuals to demonstrate

creditable coverage (and any applicable

waiting periods) as required by

§ 146.115. The description of the rights

of individuals to demonstrate creditable

coverage includes a description of the

right of the individual to request a

certificate from a prior plan or issuer, if

necessary, and a statement that the

current plan or issuer will assist in

obtaining a certificate from any prior

plan or issuer, if necessary.

§ 146.113 Rules relating to creditable

coverage.

(a) General rules)—(1) Creditable

coverage. For purposes of this section,

except as provided in paragraph (a)(2),

the term creditable coverage means

coverage of an individual under any of

the following:

(i) A group health plan as defined in

§ 144.103.

(ii) Health insurance coverage as

defined in § 144.103 (whether or not the

entity offering the coverage is subject to

the requirements of this part and 45 CFR

part 148, and without regard to whether

the coverage is offered in the group

market, the individual market, or

otherwise).

(iii) Part A or part B of title XVIII of

the Social Security Act (Medicare).

(iv) Title XIX of the Social Security

Act (Medicaid), other than coverage

consisting solely of benefits under

section 1928 of the Social Security Act

(the program for distribution of

pediatric vaccines).

(v) Title 10 U.S.C. Chapter 55

(medical and dental care for members

and certain former members of the

uniformed services, and for their

dependents; for purposes of title 10

U.S.C. chapter 55, ‘‘uniformed services’’

means the armed forces and the

Commissioned Corps of the National

Oceanic and Atmospheric

Administration and of the Public Health

Service).

(vi) A medical care program of the

Indian Health Service or of a tribal

organization.

(vii) A State health benefits risk pool.

For purposes of this section, a State

health benefits risk pool means—

(A) An organization qualifying under

section 501(c)(26) of the Code;

(B) A qualified high risk pool

described in section 2744(c)(2) of the

PHS Act; or

(C) Any other arrangement sponsored

by a State, the membership composition

of which is specified by the State and

which is established and maintained

primarily to provide health insurance

coverage for individuals who are

residents of such State and who, by

reason of the existence or history of a

medical condition—

(1) Are unable to acquire medical care

coverage for such condition through

insurance or from an HMO; or

(2) Are able to acquire such coverage

only at a rate which is substantially in