Eligible employees or their dependents may not be denied coverage under a group health plan or insurance policy because of their health condition, medical history or other evidence of insurability.  An eligible employee may not be charged higher premiums or plan contributions based on his or her health condition.

HIPAA defines a pre-existing condition as a condition (whether physical or mental) regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received.  As a result, a group plan or insurer may not define a pre-existing condition to include a condition for which a prudent person might have sought medical treatment.  Under the law, group health plans and insurers can only apply pre-existing exclusions to: 

• Late enrollies.
• Persons who have never had health insurance.
• Persons who have been previously covered health insurance for less time than the pre-existing exclusion period under the plan.
• Persons who have been uninsured for more than 63 day.

A Late Entrant is a plan member or dependent who does not enroll during: 

• The first period in which he or she is eligible to enroll or,
• A special enrollment period where thee is a change in family status or loss of group coverage under another plan.

Pre-existing exclusions are not allowed for: 

• Newborns
• Adopted children or children placed for adoption.
• Pregnancy (including late entrants)

If a pre-existing exclusion applies to a timely entrant, the maximum exclusioin period allowed is 12 months following enrollment for conditions treated within six months prior to enrollment. 

For pre-existing exclusions applying to late entrants, the maximum exclusion period allowed is 18 months following enrollment for conditions treated within six months prior to enrollment.  HMOs that do not have a pre-existing exclusion may impose an affiliation period of 60 days for timely entrants or 90 days for late entrants.

Creditable Coverage - The application of any pre-existing exclusion is reduced by the number of months in which a pre-existing exclusion is satisfied under any of the following plans: 

• An insured or self-insured group health plan
• Health insurance coverage
• Medicare
• Medicaid and Title X
• Indian Health Services
• State High Risk Pools
• Peace Corps Benefits

The Pre-existing credit does not apply to persons who have more than a 63 day lapse of coverage.  Benefit waiting periods do not count as a lapse in coverage.  When a person terminates group health coverage (Including coverage through COBRA or state continuation) an employer or the employers insurer must make available a certificate of "creditable coverage" to that person.  This certificate shows the dates during which the person was covered by a group health plan.  A person can take this certificate to his or her new group health plan and get credit towards any pre-existing exclusion perios.