Health Care Reform

Pre-Existing Conditions

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

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 ACA 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 when a plan will not provide coverage to treat a pre-existing condition until the end of the specified period, not longer than 12 months (18 months for late enrollees). HIPAA requires the plan to offset the period with “creditable coverage” (i.e., prior health plan coverage) that the 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.


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