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You are aware of the recently issued final regulations governing the portability requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). What do the regulations now require for a general notice of preexisting condition exclusion? |
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Answer: |
The regulations, which become effective on February 28, 2005 and apply for plan years beginning on or after July 1, 2005, indicate that a general notice of preexisting condition exclusion must include:
- the existence and terms of the plan's preexisting condition exclusion, including:
- the length of the plan's look-back period;
- the maximum preexisting condition exclusion period under the plan; and
- how the plan will reduce the maximum preexisting condition exclusion period by creditable coverage;
- a description of the rights of individuals to demonstrate creditable coverage, and satisfaction of any applicable waiting periods, through a certificate of creditable coverage or through other means; and
- a person to contact (including an address or telephone number) for obtaining additional information or assistance regarding the preexisting condition exclusion.
Plans can use the following sample language as a basis for preparing their own notices to satisfy the requirements in the final HIPAA regulations:
This plan imposes a preexisting condition exclusion. This means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within a six-month period. Generally, this six-month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the six-month period ends on the day before the waiting period begins. The preexisting condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 30 days after birth, adoption, or placement for adoption.
This exclusion may last up to 12 months (18 months if you are a late enrollee) from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days of your prior “creditable coverage.” Most prior health coverage is creditable coverage and can be used to reduce the preexisting condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12-month (or 18-month) exclusion period by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior health coverage, we will help you obtain one from your prior plan or issuer. There are also other ways that you can show you have creditable coverage. Please contact us if you need help demonstrating creditable coverage.
All questions about the preexisting condition exclusion and creditable coverage should be directed to Individual B at Address M or Telephone Number N.
Source: 69 FR 78719, December 30, 2004. |
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