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Health Benefits Advisor for Employers


Pre-existing Condition Exclusion

A limitation or exclusion of benefits for a condition based on the fact that you had the condition before your enrollment date in the group health plan. A pre-existing condition exclusion may be applied to your condition only if the condition is one for which medical advice, diagnosis, care or treatment was recommended or received within the 6 months before your enrollment date in the plan. A pre-existing condition exclusion cannot be applied to pregnancy (regardless of whether the woman had previous coverage), or to genetic information in the absence of a diagnosis. A pre-existing condition exclusion also cannot be applied to a newborn or a child who is adopted or placed for adoption if the child has health coverage within 30 days of birth, adoption or placement for adoption and does not later have a significant break in coverage. If a plan provides coverage to you through an HMO that has an affiliation period, the plan cannot apply a pre-existing condition exclusion. A pre-existing condition exclusion can not be longer than 12 months from your enrollment date (18 months for a late enrollee). A pre-existing condition exclusion that is applied to you must be reduced by the prior creditable coverage you have that was not interrupted by a significant break in coverage. You may show creditable coverage through a certificate of creditable coverage given to you by your prior plan or insurer (including an HMO) or by other proof. The plan can apply a pre-existing condition exclusion to you only if it has first given you written notice. If your plan has both a waiting period and a pre-existing condition exclusion, the exclusion begins when the waiting period begins. In some states, if plan coverage is provided through an insurance policy or HMO, you may have more protections with respect to pre-existing condition exclusions.

The Department has developed a model general notice of pre-existing condition exclusion and a model individual notice of pre-existing condition exclusion that can be used by a group health plan or a health insurance issuer. Correct use of the model notices will general assure compliance with regulatory requirements.


Complete Glossary of Terms