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Do HIPAA’s Preexisting Condition Rules Apply Under the Affordable Care Act?


· 5 minute read


· 5 minute read


QUESTION: We removed coverage limitations for preexisting medical conditions from our health plan in 2014 to comply with the Affordable Care Act (ACA). Do we have any continuing obligations under the HIPAA rules governing preexisting condition exclusions (PCEs)?

ANSWER: The HIPAA limitations on PCEs have been completely superseded by the ACA’s prohibition on PCEs.

HIPAA’s portability rules (enacted in 1996) included limiting the length of PCEs, requiring plans to issue certificates documenting prior creditable coverage, applying prior creditable coverage to reduce the length of PCEs, and requiring notices when a plan intends to apply a PCE to an individual. The ACA expanded these rules by prohibiting PCEs entirely, starting with the first plan year beginning on or after January 1, 2014. (PCEs for individuals under age 19 were prohibited starting with the first plan year beginning on or after September 23, 2010.)

Since the purpose of documenting creditable coverage under HIPAA was to reduce the length of PCEs and PCEs are no longer permitted, your plan has not been required to track creditable coverage or provide certificates of creditable coverage since December 31, 2014. Similarly, since PCEs can no longer be applied, HIPAA’s individual PCE notice requirement is also inapplicable.

Although the ACA supersedes the HIPAA provisions on PCEs, it does not affect HIPAA provisions requiring special enrollment periods (e.g., following loss of eligibility for other coverage) or prohibiting discrimination based on an individual’s health status.

For information about HIPAA’s portability rules, see EBIA’s HIPAA Portability, Privacy & Security manual at Sections VII (“Restrictions on Preexisting Condition Exclusions and Waiting Periods”), VIII (“HIPAA Certificate of Creditable Coverage: Obligation to Furnish”), IX (“HIPAA Certificate of Creditable Coverage: Obligations Upon Receipt”), X (“Special Enrollment Rights”), and XI (“Health Status and Genetic Information Nondiscrimination Rules”). See also EBIA’s Health Care Reform manual at Section X.B (“Prohibition on Preexisting Condition Exclusions”).

Contributing Editors: EBIA Staff.

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