A pre-existing condition is a health problem an individual suffers from before enrolling in health insurance. Pre-existing conditions may be serious, such as cancer or HIV, or relatively minor, like asthma. For many years, health insurance companies excluded people with pre-existing conditions from enrolling in their insurance, since it meant a guaranteed payout. Health insurance companies may also have put restrictions on health coverage, charged large premiums or excluded the condition from the policy. Except under certain conditions, denying a person health coverage or excluding their condition is against federal law in the United States.
The Health Insurance Portability and Accountability Act of 1996
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law which limits the ability of a health insurance company to deny coverage to someone with a pre-existing condition. HIPAA applies in all 50 states, but is supplemented by state law in many areas. Under HIPAA, a health plan is only allowed to check back six months for a condition which was present before the individual tried to enroll for health insurance. If you have not received a diagnosis, medical treatment or medical advice about the condition during these six months, then you cannot be excluded because of a pre-existing condition. If you have received treatment or advice in the previous six months, your employer's health insurance is allowed to impose an exclusion period, although this generally cannot be longer than 12 months. People with a history of prior health coverage may be able to reduce this if they can provide proof of "creditable coverage," or prior continuous health insurance. HIPAA's main problem is that it only applies to large group health insurance plans and not to individual plans. A person buying their own health insurance outside of a group is not protected under HIPAA.
Exceptions
Under HIPAA, there are some conditions which cannot be made subject to a pre-existing condition exclusion at all. Genetic information is one item which cannot exclude you from health insurance. If a person is found to be genetically predisposed toward a disease, for example, he cannot be denied coverage if he has not yet manifested the disease. If a minor child is enrolled in health care coverage within 30 days of birth, placement or adoption, she cannot be excluded for a pre-existing condition in most situations. Pregnancy can never lead to an exclusion period, even if the woman had no prior coverage. Since these rules are a part of HIPAA, they also apply in all states.
Exclusion Periods
States are allowed to mandate their own exclusion periods if HIPAA regulations do not apply, however. Maine, Massachusetts, Michigan, Indiana, Kentucky, New Jersey, New York, Washington, Idaho, Oregon and California have laws which do not allow health companies to permanently exclude non-HIPAA eligible residents from enrolling in health insurance. States also have different exclusion and look-back periods for those not covered by HIPAA. These differ according to state and whether or not you are trying to enroll in individual insurance or small group insurance. Alaska has no limit on either the exclusion or look-back period, but New Hampshire has a maximum look-back period of three months and a maximum exclusion period of nine months.
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