Note: Applies to both grandfathered and non-grandfathered plans.
For plan years beginning on or after September 23, 2010, group health plans were not allowed to impose any preexisting condition exclusion on enrollees, including applicants for enrollment, who are under the age of 19.
For plan years beginning in 2014, group health plans were not allowed to impose any preexisting condition exclusion on ANY enrollee regardless of age or health condition.
The deﬁnition of preexisting condition exclusion includes any limitation or exclusion of beneﬁts (including a denial of coverage) applicable to an individual as a result of information relating to an individual's health status before the individual's effective date of coverage (or if coverage is denied, the date of denial), such as a condition identiﬁed as a result of a pre-enrollment questionnaire or a physical examination given to the individual, or a review of medical records relating to the pre-enrollment period.
Examples include (but are not limited to):
Any other illness or sickness that occurred prior to coverage, excluding pregnancy
Excepted benefits under the ACA are not subject to this provision. They are defined as:
Benefits that are generally not health coverage (e.g. automobile insurance, work comp, AD&D, etc.)
Limited benefits such as limited-scope dental or vision benefits, long-term care, home health, etc.
Non-coordinated excepted benefit (e.g. coverage for a specific disease or illness), hospital indemnity or other fixed indemnity plan.
Supplemental except plans such as Medicare, Tricare or coverage supplemental to a group health plan and is provided under a separate policy, certificate, or contract of insurance.
Dental and vision plans are considered excepted benefits if they are provided under a separate policy or are not an integral part of a group health plan. In order to not be an integral part of a group health plan, participants must have the right to elect not to receive coverage for the benefits.