Pre-existing Condition Exclusions

The Affordable Care Act (ACA) amended the rules regarding pre-existing condition exclusions in the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The HIPAA rules applied only to group health plans and group health insurance coverage and allowed limited exclusions of coverage based on preexisting conditions under certain circumstances. However, the ACA rules:

• Prohibit any pre-existing condition from being imposed by group health

plans or group health insurance coverage; and

• Extend this protection to individual health insurance coverage.

This prohibition generally became effective with respect to plan years beginning on or after Jan. 1, 2014. However, for enrollees who are under 19 years of age, this prohibition took effect for plan years beginning on or after Sept. 23, 2010.

Overview

The ACA amended the HIPAA rules regarding pre-existing condition exclusions. The HIPAA rules:

• Applied only to group health plans and group health insurance coverage; and

• Allowed limited coverage exclusions based on pre-existing conditions under certain circumstances.

Covered Plans

The ACA’s prohibition on pre-existing condition exclusions apply to:

• Group health plans and group health insurance coverage, including grandfathered group health plans; and

• Individual health insurance coverage (but not grandfathered individual policies).

LINKS AND RESOURCES

• On June 28, 2010, the Departments of Labor (DOL), Health and Human Services (HHS) and Treasury (Departments) issued interim final rules on the pre-existing condition exclusion prohibition.

• On Nov. 18, 2015, the Departments finalized the interim final rules without substantial change, incorporating clarifications from FAQs and other subregulatory guidance.

Download the full PDF here – Pre-existing Condition Exclusions

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