For plan years beginning on or after Jan. 1, 2014, the Affordable Care Act (ACA) prohibits group health plans and issuers from imposing pre-existing condition exclusions (PCEs) on any enrollees.
Currently, ACA prohibits PCEs for enrollees who are under 19 years of age. ACA’s restrictions on PCEs apply to both grandfathered and non-grandfathered plans.Until ACA’s full prohibition on PCEs takes effect in 2014, the HIPAA rules regarding PCEs will continue to apply. HIPAA currently allows plans and issuers to exclude pre-existing conditions from coverage, but places significant limitations on those exclusions. For example, the length of any PCE must be reduced by the amount of creditable coverage the individual had prior to enrollment in the plan. An individual’s prior creditable coverage is documented in a HIPAA Certificate of Creditable Coverage, provided by the prior plan or issuer.
ACA’s prohibition on PCEs for plan years beginning on or after Jan. 1, 2014, will eventually make HIPAA Certificates unnecessary.
Proposed rules issued on March 21, 2013, state that the requirement to provide HIPAA certificates will be eliminated effective Dec. 31, 2014. The need for plans to continue providing HIPAA Certificates during 2014 recognizes that participants may need HIPAA Certificates during 2014 to avoid PCEs under non-calendar year plans. Although the proposed rule is not yet in final form, plans and issuers should plan on providing HIPAA Certificates during 2014.