Preexisting Condition Exclusions

A fully insured small employer plan can exclude coverage for preexisting conditions for up to 12 months (18 months for a late enrollee) after an individual's enrollment date. Any preexisting condition exclusion must be reduced by an individual's prior creditable coverage. No preexisting condition may be applied to an individual who maintains continuous creditable coverage (without a break of 63 or more days) for 12 months (18 months for a late enrollee).

A preexisting condition exclusion is a limitation or exclusion of health benefits based on the fact that a physical or mental condition was present before the first day of coverage. A preexisting condition exclusion is limited to a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within the 6-month period ending on the enrollment date in a plan or policy.

During the preexisting condition exclusion period, the plan or issuer may not cover or pay for treatment of a medical condition based on the fact that the condition was present prior to an individual's enrollment date under the new plan or policy. (The plan or issuer must, however, pay for any unrelated covered services or conditions that arise once coverage has begun.) The enrollment date is the first day of coverage, or if there is a waiting period before coverage takes effect, the first day of the waiting period.

Conditions that may not be considered "preexisting:"

  • Pregnancy may not be considered a preexisting condition. In other words, if you are pregnant when you join your new employer group health plan, your pregnancy must be covered.
  • Genetic information may not be considered a preexisting condition if there is no specific diagnosis of a current disease or medical problem related to the genetic test.
  • Services provided for children adopted or placed for adoption before 18 years of age.