Pre­-Existing Conditions

A pre­existing 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.

A pre­existing condition limit is when a plan will not provide coverage to treat a preexisting 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 63­day break in coverage).

Example: A plan imposes a 12 month pre­existing condition period. A newly­ hired employee who enrolls in the plan has a pre­existing 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 pre­existing condition for the first 5 months, but after that would have to provide coverage for the pre­existing condition

No, under proposed regulations, the Agencies no longer require a certificate of creditable coverage after December 31, 2014.