ACA: Elimination of Pre-existing Conditions


 The Affordable Care Act (ACA) amended the HIPAA portability rules relating to preexisting condition exclusions. The ACA limits application of preexisting condition exclusions in group health plans and health insurance coverage and eliminates such exclusions in their entirety effective for plan years beginning on or after January 1, 2014. See below for details.

The ACA requires all preexisting condition exclusions and limitations to be eliminated from group health plan provisions for plan years beginning on or after January 1, 2014.

The statute also amends the definition of a preexisting condition exclusion (PCE) under HIPAA’s portability rules to clarify that a PCE includes both a coverage exclusion for specific benefits associated with a particular preexisting condition, and a complete exclusion from such plan or coverage based on the preexisting condition. However, it remains permissible under current rules for plans to exclude benefits for a particular condition, as long as the exclusion applies to all similarly-situated plan participants regardless of when the condition arose, and regardless of the effective date of the plan or coverage with respect to a participant.

A Preexisting Condition is a medical condition present before enrollment date in any new group health plan. The only preexisting conditions that may be excluded under a preexisting condition exclusion are those for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period before the enrollment date.

With the elimination of pre-existing condition exclusions under health care reform, employers will no longer need to track the length of coverage or provide certificates of creditable coverage. 

For additional information on special enrollments, click here.