Health Benefits Advisor for Employers

Determining Compliance with the HIPAA Provisions in Part 7 of ERISA

Limits on Preexisting Condition Exclusions - Reconsideration

If the plan determines that an individual does not have the creditable coverage claimed, and the plan wants to modify an initial determination of creditable coverage, does the plan comply with the rules relating to reconsideration?

• Yes
• No

A plan may modify an initial determination of an individual's creditable coverage if the plan determines that the individual did not have the claimed creditable coverage, provided that:

• A notice of the new determination is provided to the individual; and
• Until the new notice is provided, the plan, for purposes of approving access to medical services, acts in a manner consistent with the initial determination of creditable coverage. See 29 CFR 2590.701-3(f).