Sample general notice of preexisting condition exclusion under HIPAA

A group health plan may not impose a preexisting condition exclusion with regard to a participant or dependent before giving a written notice to the participant that discloses the existence and terms of the exclusion and the right of the participant to demonstrate creditable coverage for himself and on behalf of his dependents (see ¶42,415).

Plans can use the following sample language as a basis for preparing preexisting condition exclusion notices to satisfy the requirements in the final HIPAA regulations:

This plan imposes a preexisting condition exclusion. This means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within a six-month period. Generally, this six-month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the six-month period ends on the day before the waiting period begins. The preexisting condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 30 days after birth, adoption, or placement for adoption.This exclusion may last up to 12 months (18 months if you are a late enrollee) from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. However, you can reduce the length of this exclusion period by the number of days of your prior creditable coverage. Most prior health coverage is creditable coverage and can be used to reduce the preexisting condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 12-month (or 18-month) exclusion period by your creditable coverage, you should give us a copy of any certificates of creditable coverage you have. If you do not have a certificate, but you do have prior health coverage, we will help you obtain one from your prior plan or issuer. There are also other ways that you can show you have creditable coverage. Please contact us if you need help demonstrating creditable coverage.All questions about the preexisting condition exclusion and creditable coverage should be directed to Individual B at Address M or Telephone Number N.