Health Benefits Advisor for Employers

Determining Compliance with the HIPAA Provisions in Part 7 of ERISA

Limits on Preexisting Condition Exclusions - Individual Notices

Does the plan provide adequate and timely individual notices of preexisting condition exclusions?

• Yes
• No

After an individual has presented evidence of creditable coverage and after the plan has made a determination of creditable coverage (See 29 CFR 2590.701- 3(d)), the plan must provide the individual a written notice of the length of preexisting condition exclusion that remains after offsetting for prior creditable coverage. See 29 CFR 2590.701-3(e).

Exception: A plan is not required to provide this notice if the plan's preexisting condition exclusion is completely offset by the individual's prior creditable coverage. See 29 CFR 2590.701-3(e).

• The notice must disclose:
• The determination of the length of any preexisting condition exclusion that applies to the individual (including the last day on which the preexisting condition exclusion applies);
• The basis for the determination, including the source and substance of any information on which the plan relied;
• An explanation of the individual's right to submit additional evidence of creditable coverage; and a description of any applicable appeal procedures established by the plan. See 29 CFR 2590.701-3(e)(2).

The individual notice must be provided by the earliest date following a determination that the plan, acting in a reasonable and prompt fashion, can provide the notice. See 29 CFR 2590.701-3(e)(1).

Tips: Ensure that individual notices are complete and timely as well. A model notice is provided by EBSA.