Pre-Existing Conditions

For plan years beginning on or after September 23, 2010, health plans may not impose any pre-existing condition limits for participants and beneficiaries under age 19.  For plan years beginning on or after January 1, 2014, plans may not impose any pre-existing condition exclusions for any participants and beneficiaries.

Note: The limit on pre-existing conditions only applies to certain types of health plans, such as major medical insurance.  It does not apply to HIPAA excepted benefits, such as disability, cancer, hospital indemnity, or accident  insurance.  Click here for more information about the types of benefits that are exempt from the Health Care Reform plan design mandates.

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Pre-Existing Condition Limit Hot Topics & FAQs

  • What is a pre-existing condition?

    Answer: A pre-existing condition is a health condition, disease, illness, or injury for which medical advice, diagnosis, care, or treatment was received or recommended within a specified time period prior to enrolling in a health plan.

  • What’s a pre-existing condition limit?

    Answer: A pre-existing condition limit is a period of time during which a plan will not provide coverage to treat a pre-existing condition. Under HIPAA, a pre-existing condition period can’t exceed 12 months (18 months for late enrollees), and must be reduced by any period of “creditable coverage” (i.e., prior health plan coverage) that an individual had prior to joining the plan (after not more than a 63-day break in coverage).

    Example:  A plan imposes a 12 month pre-existing condition period. A newly-hired employee who enrolls in the plan has a pre-existing condition but also had creditable health plan coverage for the 7 months immediately prior to enrollment. That 7-month period of creditable coverage would reduce the 12-month limitation period to 5 months. The plan could deny coverage to treat the pre-existing condition for the first 5 months, but after that would have to provide coverage for the pre-existing condition.

  • Are plans still required to provide HIPAA certificates of creditable coverage?

    Answer: No, under proposed regulations, the Agencies would no longer require certificates of creditable coverage after December 31, 2014.

American Fidelity Assurance Company does not provide tax or legal advice.

ESB-825(0713)

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