Texas General Lines — Life, Accident, Health and HMOTexas Statutes and Rules Specific to Accident, Health and HMOMedium
A Texas resident is covered by an individual health insurance policy that contains a provision limiting benefits for pre-existing conditions. Under Texas law, what is the maximum exclusionary period for a pre-existing condition in an individual health insurance policy if the insured has no prior creditable coverage?
- A12 months
- B3 months
- C24 months
- D6 months
Show answer & explanationAnswer & explanation
Correct answer: A. 12 months
Texas law, consistent with HIPAA, limits the pre-existing condition exclusion period for individual health insurance policies to a maximum of 12 months for conditions for which medical advice, diagnosis, care, or treatment was received or recommended during the 6-month period ending on the enrollment date.
Why the other options are wrong
- B. This period is too short for the maximum allowed under Texas law for pre-existing conditions without prior creditable coverage.
- C. This period is longer than the maximum allowed under Texas law for pre-existing conditions without prior creditable coverage.
- D. This period is sometimes relevant for look-back periods, but not the maximum exclusion period for pre-existing conditions.
Pre-existing Condition Exclusion (TX Individual Health)
A period during which an individual health insurance policy will not pay for medical expenses related to a pre-existing condition, as defined by the policy and state law.
- Maximum 12 months in Texas for individual policies.
- Applies to conditions treated/diagnosed 6 months prior to enrollment.
- Creditable coverage can reduce or eliminate this period.
Memory trick: Texas health policies have a 'Pre-Ex' clause, but it's limited to a 'Year' to keep things fair.