Eligibility Eligible employees or their dependents may not be denied coverage under a group health care plan or insurance policy because of their health condition, medical history or other
evidence of insurability. An eligible employee may not be charged higher premiums or plan contributions based on his or her health condition. Limitation on Pre-existing exclusions HIPAA defines 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. As a result, a group plan or insurer
may not define a pre-existing condition to include a condition for which a prudent person might have sought medical treatment. Under this law, group health plans and insurers can only apply pre-existing exclusions to:
- Late entrants
- Persons who have never had health insurance
- Persons who have been previously covered by health insurance for less time than the pre-existing exclusion period under the plan.
- Persons who have been uninsured for more than 63 days.
A Late Entrant is a plan member or dependent who does not enroll during:
- The first period in which he or she is eligible to enroll or ,
- A special enrollment period where there is a change in family status or loss of group coverage under another plan.
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 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 following enrollment for conditions treated within six months prior to enrollment. HMOs that do not use a
pre-existing exclusion may impose an "affiliation" period of 60 days for timely entrants or 90 days for late entrants. CREDIT for prior health insurance (creditable coverage) The application of any
pre-existing exclusion is reduced by the number of months in which a pre-existing exclusion is satisfied under any one of the following plans:
- An insured or self-insured group health plan
- Health insurance coverage
- Medicare
- Medicaid and Title X
- Indian Health Services
- State High Risk Pools
- Public Health Plans
- Peace Corps Benefits
The Pre-existing credit does not apply to persons who have more than a 63 days lapse in coverage. Benefit waiting periods do not count as a lapse in coverage. When a person loses group health coverage( Including
coverage though COBRA or state continuation) an employer or the employers insurer must make available a certificate of "creditable coverage" to that person. This certificate shows the dates during which the
person was covered by a group health plan. A person can take this certificate to his or her new group health plan and get credit towards any pre-existing exclusion period. Special Enrollment Periods
Employees or dependents who would otherwise be late entrants may enroll without penalty when a change in family states or loss of other group insurance occurs. Employees or dependents are allowed to enroll in a group plan within 30 days following:
1. A loss of eligibility for group coverage under another plan due to :
- Separation
- Divorce
- Death
- Termination of employment
- reduction in work hours
- employer contribution toward coverage have terminated
- termination of COBRA or state continuation
2 . A change in family status due to:
- marriage
- birth of a child
- adoption or placement for adoption of a child.
Employees or dependent spouses who are otherwise eligible but not enrolled in the plan, can also enroll during the special enrollment periods when a change in family status occurs. Persons who
enroll under these special enrollment conditions are not considered late entrants. |
