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LIMITATIONS ON PRE-EXISTING CONDITION EXCLUSIONS

HIPAA regulations define a pre-existing condition as:

"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 6-month period ending on the enrollment date."

Under this law, group health plans and insurers can only apply pre-existing exclusions to:

late entrants (see definition below)

persons who have never had health coverage

persons who have previously had health coverage for less time than the pre-existing exclusion period under the plan

persons who have been without coverage for more than 63 days. (see The Role of State Laws in HIPAA)

A late entrant is a plan member or dependent who does not enroll during:

the first period in which she/he is eligible to enroll; or

a special enrollment period when thee is a change in family status or loss of group coverage under another plan (see Special Enrollment Periods).

Pre-existing exclusions are not allowed for:

newborns

adopted children or children placed for adoption

pregnancy (including late entrants)

If a pre-existing exclusion applies to a timely entrant, the maximum exclusion period allowed is 12 months (365 days) following enrollment for conditions treated within six months prior to enrollment.

For pre-existing exclusions applying to late entrants, the maximum exclusion period allowed is 18 months (546 days) following enrollment for conditions treated within six months prior to enrollment.

HMO's that do not use a pre-existing exclusion may impose a "affiliation" period of 60 days for timely entrants or 90 days for late entrants.

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