Pre-Existing Conditions

Pre-Existing Conditions

by Posted on: September 2, 2014Categories: HR & Compliance   

The Affordable Care Act (ACA) amended the rules regarding pre-existing condition exclusions in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HIPAA rules applied only to group health plans and group health insurance coverage, and permitted limited exclusions of coverage based on pre-existing conditions under certain circumstances.

However, the ACA rules prohibit any pre-existing condition from being imposed by group health plans or group health insurance coverage, and extend this protection to individual health insurance coverage. This prohibition generally is effective with respect to plan years beginning on or after Jan. 1, 2014. However, for enrollees who are under 19 years of age, this prohibition took effect for plan years beginning on or after Sept. 23, 2010.

On June 28, 2010, the Departments of the Treasury, Labor (DOL) and Health and Human Services (HHS) issued interim final rules related to the health care reform requirements for pre-existing condition exclusions.

Pre-Existing Condition Exclusion Defined

A pre-existing condition exclusion is a limitation or exclusion of benefits related to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before that date.

Based on this definition, the ACA prohibits both exclusions of coverage of specific benefits and complete exclusions from a plan or coverage based on a pre-existing condition.

However, the ACA’s pre-existing condition exclusion rules do not change the HIPAA rule that an exclusion of benefits for a certain condition under a plan is not a pre-existing condition exclusion if the exclusion is not based on the date the condition arose. For example, if a group health plan generally provides coverage for medically necessary services, but excludes coverage for the treatment of cleft palate, the exclusion of coverage for treatment of cleft palate is not a pre-existing condition exclusion because it applies regardless of when the condition arose.


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