HIPAA changes how plans and issuers may apply preexisting condition exclusions. What does that mean?
A “preexisting condition exclusion” is a limitation or exclusion of health benefits based on the fact that a physical or mental condition was present before the first day of coverage. However, HIPAA limits the extent to which a plan or issuer can apply a preexisting condition exclusion. A preexisting condition exclusion is limited to a physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 month period ending on the enrollment date in a plan or policy. During the preexisting condition exclusion period, the plan or issuer may opt not to cover or pay for treatment of a medical condition based on the fact that the condition was present prior to an individual’s enrollment date under the new plan or policy. (The plan or issuer must, however, pay for any unrelated covered services or conditions that arise once coverage has begun.) The enrollment date is the first day of coverage, or if there is a waiting period before cov
