What Does Pre-Existing Condition Exclusion Period Mean?

Pre-Existing Condition Exclusion Period is a health insurance benefit provision that places limits on benefits or excludes benefits for a period of time due to a medical condition that the policyholder had prior to enrolling in a health plan. Pre-existing condition exclusion periods are regulated policy features, meaning that the insurer is likely to have an upper limit on the period of time the exclusion period will last.

Pre-Existing Condition Exclusion Period Explained

A pre-existing condition exclusion period limits the amount of benefits that an insurer has to provide for specific medical conditions, and does not apply to medical benefits afforded by a health insurance policy for other types of care. For example, a policyholder may be excluded from receiving benefits for a pre-existing heart condition for a period of months after starting a policy, but may still receive care for non-preexisting conditions, such as the flu.

Conditions for Exclusion

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires insurers to provide coverage to individuals in group health plans, and places restrictions on how insurers can restrict some benefits. It set guidelines on how and when insurers could exclude health coverage from individuals who had pre-existing conditions before joining the policy. HIPAA allows insurers to refuse to cover pre-existing medical conditions for up to the first twelve months after enrollment, or eighteen months in the case of late enrollment.

Individuals can reduce the pre-existing condition exclusion period by proving that they had creditable coverage before joining the new plan. The individual can prove this by showing a certificate of creditable coverage produced by the previous insurer, or may offer other forms of proof.

Insurers have to provide a written notice indicating that a pre-existing condition is being applied, and the exclusion period countdown begins immediately after any plan-required waiting period. In some states, insurers may have additional restrictions placed on whether they can include a pre-existing condition exclusion period.

Under the Affordable Care Act passed in 2010, "Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer. They cannot limit benefits for that condition either. Once you have insurance, they can't refuse to cover treatment for your pre-existing condition."