Individuals & Families Employers Brokers Physicians Health & Wellness

Pre-Existing Conditions

Timeline of Provisions

Pre-Existing Conditions

Under Age 19


Beginning Sept. 23, 2010, group health plans cannot exclude enrollees (employees, spouses or dependents) under age 19 based on pre-existing conditions. For other plans, all pre-existing condition exclusions must be removed beginning in 2014.

Grandfathered group health plans receive no special protection and must comply once the provision becomes effective with respect to the plan. These rules apply equally to collectively bargained and non-collectively bargained plans.

A special rule applies to individual health insurance coverage. The pre-existing condition rules only apply to non-grandfathered individual health insurance plans.

A temporary high-risk health insurance pool provides coverage for eligible individuals who have been denied health care coverage.

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Frequently Asked Questions

If an employer group is an ERISA plan year group yet doesn't renew their UnitedHealthcare policy until 4-1-11, do they have make all applicable health care reform changes for 1-1-11?

UnitedHealthcare is using selected plan year renewal on or after 9-23-10 (which normally coincides with the ERISA plan year) to implement the changes for healthcare reform. If a client is advised by their own counsel to make the changes on the basis of another 12-month period of time, UnitedHealthcare will accommodate the changes as needed.

Does the law apply to any enrollee under the age of 19, or just dependent children?

The law includes any enrollee under the plan who is under 19. For example, an enrollee could be an employee, spouse, or dependent child.

What is the effective date of the pre-existing condition limits?

This provision became effective for plan/policy years beginning on or after September 23, 2010, for enrollees under age 19. For our calendar year customers, the new law prevented the use of a pre-existing condition exclusion in the case of persons under age 19 as of January 1, 2011.

In the case of all other enrollees (age 19 and older), protection from pre-existing condition exclusions becomes effective for plan/policy years beginning on or after January 1, 2014.

Individual Coverage: A special rule applies to the health insurance coverage offered in the individual market. The new pre-existing condition rules only apply to individual health insurance coverage that is a non-grandfathered health plan. The new rules do not apply to grandfathered health plans in the individual market.

How does the pre-existing condition limitation for children under 19 work with the current HIPAA/continuous creditable coverage exception for newborn/newly adopted children?

The current HIPAA exception reads as follows: "This exclusion does not apply to newborn children, newly adopted children or children placed for adoption. This exception for newborn, adopted children and children placed for adoption no longer applies after the end of the first 63-day period during which the child has not had Continuous Creditable Coverage."

There is no need for the above provision after the effective date of the new law. This is because newborns and newly adopted children are, by definition, under the age of 19 and would be protected by the pre-existing condition prohibition contained in the new law. (While it may be theoretically possible that persons over the age of 19 could be adopted, those persons are not protected under the special HIPAA rule. That rule only protects adopted children (or children placed for adoption) up until the age of 18. Thus, there is no need for plans and policies to contain the special HIPAA rule even in the case of adoptions.

Would the Continuous Creditable Coverage concept apply only to enrollees 19 and over?

Yes. For the time being, plans may still impose pre-existing conditions on persons who are age 19 and older. These enrollees will, however, be allowed to use their Credible Coverage to offset a pre-existing condition exclusion as is the case under current law. In 2014, the prohibition on pre-existing conditions will apply to all members, regardless of age.

How is the pre-existing condition handled for enrollees over the age of 19?

Same as today, the pre-existing condition exclusion is still in force, subject to HIPAA's credible coverage rules which operate to offset the exclusion.

How will pre-existing condition claims be processed?

The system will automatically set the various "Pre-Ex" fields to the appropriate value for new members and existing members upon renewal to ensure claims are processed properly.

If the member turns 19 during the plan year, will you reinstate the pre-existing exclusion?

No. The operational decision will be leave the member coverage in place until the next plan year renewal.

Is the pre-existing exclusion impacted by Grandfathering?

Not in the group market. In the group market, the new pre-existing condition rules apply equally to grandfathered and non grandfathered plans alike.

A special rule, however, applies to health insurance coverage offered in the individual market. The new pre-existing condition rules do NOT apply to grandfathered health plans that are individual health insurance coverage. The new rules ONLY apply to the non-grandfathered plans in the individual health insurance market.