Can coverage for a preexisting condition be denied under HIPAA?

Preexisting condition rules. Preexisting conditions are medical conditions that have been identified or treated prior to the time that an employee or covered dependent becomes eligible for plan coverage. Under HIPAA, the ability of most group health plans or health insurers, including HMOs, to exclude an individual from health coverage due to a preexisting condition is restricted.

Six-month lookback rule. A preexisting condition exclusion is permissible if it relates to a physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received within six months before the enrollment date in the new plan. Conditions not diagnosed, treated, etc., during that six-month period prior to the enrollment date are not subject to any coverage exclusion. For these purposes, genetic information is not a condition. If an employee had a medical condition but did not seek treatment within the six-month period immediately prior to enrollment, it is not a preexisting condition and no exclusion would apply.

The six-month lookback period is based on the six-month anniversary date of the enrollment date. As a result, an employee whose enrollment date is August 1, 2005 has a six-month lookback period from February 1, 2005 through July 31, 2005.

Exclusion period. The exclusion period for preexisting conditions may last for only 12 months (18 months for late enrollees) after the enrollment date. Enrollment date is the earlier of (1) the date that the individual enrolled or (2) the first day of the waiting period. However, the enrollment date for a late enrollee or anyone who enrolls on a special enrollment date is the first date of coverage. As a result, the time between the date a late enrollee or special enrollee becomes eligible for enrollment under the plan and the first day of coverage is not treated as a waiting period. Late enrollees are participants or beneficiaries who enroll in the plan other than when first eligible or under a special enrollment period (See ¶42,430 ) The 12-month (or 18-month) exclusion period must be reduced for periods of creditable coverage (see ¶42,420 ).

Exceptions. A preexisting condition limitation period cannot be applied to the following:

• any person who has a condition relating to pregnancy;

• a newborn child who is enrolled within 30 days after birth; and

• a child who is placed for adoption before age 18 and is timely enrolled.

Notice required. A group health plan may not impose a preexisting condition exclusion with regard to a participant or dependent before giving a written notice to the participant that discloses the existence and terms of the exclusion and the right of the participant to demonstrate creditable coverage for himself and on behalf of his dependents (see ¶42,420 ).

A general notice of preexisting condition exclusion must include:

• the existence and terms of the plan's preexisting condition exclusion, including:

  • the length of the plan's look-back period;

  • the maximum preexisting condition exclusion period under the plan; and

  • how the plan will reduce the maximum preexisting condition exclusion period by creditable coverage;

• a description of the rights of individuals to demonstrate creditable coverage, and satisfaction of any applicable waiting periods, through a certificate of creditable coverage or through other means; and

• a person to contact (including an address or telephone number) for obtaining additional information or assistance regarding the preexisting condition exclusion.

A sample general notice of preexisting condition exclusion can be found at ¶15,825 .