HIPAA and Pre-Existing Conditions
Prior to passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), nothing prevented group health plans and insurers from refusing to extend medical benefits to job changers who wanted coverage for ongoing medical conditions continued under a new employer's group health plan. HIPAA increased portability of health insurance by limiting a plan or insurer's ability to exclude coverage for preexisting health conditions.
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Exclusion Defined
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Any health plan's refusal or limitation of coverage for a medical condition present before the plan effective date, regardless of whether or not the individual received diagnosis or treatment before that date, meets HIPAA's definition of a preexisting condition exclusion. This definition applies to a group health plan's current insurance issuer and any succeeding firm that underwrites the group health plan, according to U.S. Department of Health & Human Services final regulations for HIPAA.
Six-Month Look-Back Rule
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Under HIPAA's portability provisions, a plan or insurer can exclude or limit benefits on prior health conditions only if the individual received medical advice, diagnosis, care or treatment during the six-month period before the new group health plan enrollment date. (Typically enrollment begins the employee's first work day.) For example, if a person with arthritis for several years didn't receive medical advice or treatment for it during the six months before enrolling in his current employer's group health plan, the insurer can't exclude arthritis care from coverage, according to a U.S. Department of Labor fact sheet.
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Restrictions on Exclusions
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Group health plans or insurers can't impose preexisting condition exclusions on an individual's genetic information, a pregnancy or on a child enrolled in health coverage within 30 days of birth, adoption or placement for adoption. Health plans can't impose preexisting condition exclusions longer than 12 months after the enrollment date (18 months for a late enrollee). The plan or insurer also must reduce the length of the exclusion by the number of days of coverage the individual had before enrollment in the new group health plan.
Reducing the Exclusion Period
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Coverage that can shorten the exclusion period may include participation in a spouse's group health plan, continuation of benefits under COBRA, or coverage under an individual health policy, Medicare, Medicaid or SCHIP. The group health plan or insurer may not have to credit prior coverage toward the exclusion period if an individual hasn't had health insurance for more than 63 days. Group health plans and insurers also must provide a general written notice of preexisting condition exclusions with enrollment application materials.
Additional Provisions
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HIPAA portability provisions also outlaw group health plans and insurers from denying coverage to individuals based on health status, medical conditions, previous claims, receipt of health care, medical history and disability. Health plans can't consider conditions that may result from domestic violence or participation in sports like motorcycling or skiing when determining eligibility for coverage. The regulation also prevents health plans from charging someone a higher premium based on a health factor or requiring individuals to pass a physical exam to enroll.
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