Health Benefits Advisor for Employers

Determining Compliance with the HIPAA Provisions in Part 7 of ERISA

Limits on Preexisting Condition Exclusions - Offsetting the Length by Creditable Coverage

Does the plan offset the length of its preexisting condition exclusion by an individual's creditable coverage?

• Yes
• No

The length of the plan's preexisting condition exclusion must be offset by the number of days of an individual's creditable coverage. However, days of coverage prior to a "significant break in coverage" are not required to be counted as creditable coverage. Under Federal law, a significant break in coverage is a period of 63 days or more without any health coverage. See ERISA section 701(a)(3); 29 CFR 2590.701-3(a)(2)(iii).

Definition: Creditable coverage means coverage of an individual under any of the following:

• A group health plan (including COBRA coverage),
• Health insurance coverage,
• Medicare,
• Medicaid,
• TRICARE,
• The Indian Health Service,
• A State health risk benefit pool,
• The Federal Employee Health Benefit Program,
• A public health plan,
• Peace Corps Act health benefits, or
• The State Children's Health Insurance Program. See ERISA section 701(c); 29 CFR 2590.701-4(a)(1).