elaws - Health Benefits Advisor for Employers

Health Benefits Advisor for Employers

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

A group health plan may not impose a preexisting condition exclusion with respect to a participant or dependent before notifying the participant, in writing, of:

The existence and terms of any preexisting condition exclusion under the plan. This includes the length of the plan's look-back period, the maximum preexisting condition exclusion period under the plan, and how the plan will reduce this maximum by creditable coverage.
A description of the rights of individuals to demonstrate creditable coverage (and any applicable waiting periods) through a certificate of creditable coverage or through other means. This must include: (1) a description of the right of the individual to request a certificate from a prior plan or issuer, if necessary; and (2) a statement that the current plan or issuer will assist in obtaining a certificate from any prior plan or issuer, if necessary.
A person to contact (including an address or telephone number) for obtaining additional information or assistance regarding the preexisting condition exclusion. See 29 CFR 2590.701-3(c)(2).

The general notice is required to be provided as part of any written application materials distributed for enrollment. If a plan does not distribute such materials, the notice must be provided by the earliest date following a request for enrollment that the plan, acting in a reasonable and prompt fashion, can provide the notice. See 29 CFR 2590.701-3(c)(1).

Tips: Ensure that the general notice is both complete and timely. The plan can include its general notice of preexisting condition exclusion in the summary plan description (SPD) if the SPD is provided as part of the application materials. If not, this general notice must be provided separately to be timely. A model notice is provided by EBSA.