U.S. Department of Labor
Health Benefits Advisor for Employers
Determining Compliance with the HIPAA Provisions in Part 7 of ERISA
Compliance with HIPAA Nondiscrimination Provisions - Eligibility
Does the plan allow individuals eligibility and continued eligibility under the plan regardless of any adverse health factor?
Examples of plan provisions that violate ERISA section 702(a) because they discriminate in eligibility based on a health factor include: Plan provisions that require "evidence of insurability," such as passing a physical exam, providing a certification of good health, or demonstrating good health through answers to a health care questionnaire in order to enroll. See 29 CFR 2590.702(b)(1).
Also, note that it may be permissible for plans to require individuals to complete physical exams or health care questionnaires for purposes other than for determining eligibility to enroll in the plan, such as for determining an appropriate blended, aggregate group rate for providing coverage to the plan as a whole. See 29 CFR 2590.702(b)(1)(iii) Example 1.
Tip: Eliminate plan provisions that deny individuals eligibility or continued eligibility under the plan based on a health factor, even if such provisions apply only to late enrollees.
