Health insurance Portability and Accountability Act (HIPAA)
If I get health insurance through my employer, is there a federal law that limits how my plan will exclude my pre-existing condition?
Yes. The Health insurance Portability and Accountability Act (HIPAA) of 1996, limits the pre-existing conditions that health insurance plans can exclude from coverage.
The only pre-existing conditions your insurance plan may exclude are for those you received or someone recommended you receive medical advice, diagnosis, care, or treatment during the six months prior to your enrollment date. Your enrollment date is your first day of coverage, or if there is a waiting period, it’s the first day of your waiting period (typically, your date of hire).
If you had a medical condition in the past, but you have not received any medical advice, diagnosis, care, or treatment for it within the six months prior to enrolling in the plan, your old condition is not considered a pre-existing condition. As a result, an exclusion does not apply.
Washington state law shortened this six-month period to three months for group insurance policies for employers purchase who have 50 or more employees.
Legally, what is the limit on the group insurance pre-existing condition exclusion?
For self-funded employers, the federal Health Insurance Portability and Accountability Act (HIPAA) permits health plans to require a 12-month pre-existing condition exclusion period.
For large groups (more than 50 eligible employees), state-regulated health insurers may require a three-month pre-existing condition exclusion period.
For small groups (1-50 eligible employees), state-regulated health insurers may require a nine-month pre-existing condition exclusion period.
I changed employment and my new group health plan imposes a pre-existing condition exclusion period. How does my new plan determine the length of my pre-existing condition exclusion period?
Under federal HIPAA law, your new plan must reduce your maximum pre-existing condition exclusion period by the number of days you had creditable coverage in your prior health coverage. However, the HIPAA law does not require your plan to take into account any days of creditable coverage that precede a break in coverage of 63 days or more (significant break in coverage).
For example, suppose you had coverage for two continuous years followed by a 70-day break in coverage and you then resumed coverage for eight months. You would only receive credit for the eight months of coverage. You would not receive credit for the two years of coverage prior to the 70-day break in coverage.
For state-regulated large- and small-group insurance plans, state law lengthens the significant break in coverage to 90 days. However, these plans must reduce your maximum pre-existing condition waiting period to only the amount of time you had continuous, similar coverage under an immediately, preceding health insurance