a. Pre-existing Conditions

 
 
 
Current and pending pre-existing condition exclusion regulation in the United States

Regulation of pre-existing condition exclusions in individual (non-group) and small group (2 to 50 employees) health insurance plans in the United States is left to individual U.S. states as a result of the McCarran–Ferguson Act of 1945 which delegated insurance regulation to the states and the Employee Retirement Income Security Act of 1974 (ERISA) which exempted self-insured large group health insurance plans from state regulation. After most states had by the early 1990s implemented some limits on pre-existing condition exclusions by small group (2 to 50 employees) health insurance plans, the Health Insurance Portability and Accountability Act (Kassebaum-Kennedy Act) of 1996 (HIPAA) extended some minimal limits on pre-existing condition exclusions for all group health insurance plans—including the self-insured large group health insurance plans that cover half of those with employer-provided health insurance but are exempt from state insurance regulation.[6]

Current pre-existing condition exclusion regulation

Individual (non-group) health insurance plans[7]

Small group (2 to 50 employees) health insurance plans[8]

Large group (self-insured) health insurance plans

  • Maximum pre-existing condition exclusion period
    • 12 months — 50 states + DC
  • Maximum look-back period for pre-existing conditions
    •   6 months — 50 states + DC

* Pre-existing condition exclusions are prohibited for HIPAA-eligible individuals (those with 18 months continuous coverage unbroken for more than 63 days and coming from a group health insurance plan).
* Individual (non-group) health insurance plans may exclude maternity coverage for a pre-existing condition of pregnancy.[4]
* Group health insurance plans sponsored by employers with 15 or more employees were prohibited by the
Pregnancy Discrimination Act of 1978 from excluding maternity coverage for a pre-existing condition of pregnancy; this prohibition was extended to all group health insurance plans by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).[4]

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