Pre-existing condition exclusion period (individual policy) - Glossary (2024)

FAQs

Pre-existing condition exclusion period (individual policy) - Glossary? ›

A pre-existing condition exclusion period limits the number of benefits that an insurer has to provide for specific medical conditions and does not apply to medical benefits afforded by a health insurance policy for other types of care.

The time period during which a health plan won't pay for care relating to a pre-existing condition. Under a job-based plan, this cannot exceed 12 months for a regular enrollee or 18 months for a late-enrollee.

Health insurers can no longer charge more or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer, as well as pregnancy. They cannot limit benefits for that condition either.

A long-term care insurance policy or certificate, other than a policy or certificate that is issued to a group, may not exclude coverage for a loss or confinement that is the result of a preexisting condition unless the loss or confinement begins within six months following the effective date of coverage of an insured ...

Pre-existing conditions are excluded from coverage if a disability due to the condition begins in the first 12 months after your effective date of coverage, unless you have been treatment-free from the pre-existing condition for 3 consecutive months after your effective date.

Understanding waiting periods

This period could be anywhere from 12-18 months, meaning that if you receive treatment for your condition prior to this period having passed, then you must pay for costs out-of-pocket. To understand the specifics of your plan, contact your health insurance provider.

A pre-existing condition exclusion period limits the number of benefits that an insurer has to provide for specific medical conditions and does not apply to medical benefits afforded by a health insurance policy for other types of care.

If your health plan is fully compliant with the ACA and obtained in either the individual/family market or the employer-sponsored market, you no longer need to worry about pre-existing condition exclusion periods.

Pre-existing Condition Exclusion. A limitation or exclusion of benefits for a condition based on the fact that you had the condition before your enrollment date in the group health plan.

The time period during which an individual policy won't pay for care relating to a pre-existing condition. Under an individual policy, conditions may be excluded permanently (known as an "exclusionary rider"). Rules on pre-existing condition exclusion periods in individual policies vary widely by state.

How long can an insurer exclude coverage for a pre-existing condition quizlet? ›

(Health insurers may exclude coverage for pre-existing conditions for up to 12 months following the enrollment date.

The period of time that a group health plan can legally limit your access to the health benefits offered by that plan because of a pre-existing condition. Under HIPAA, the maximum pre-existing condition exclusion period that can be applied to an individual is 12 months (18 months for late enrollees).

The Affordable Care Act (ACA or “Obamacare”) prohibited pre-existing condition exclusions for all plans beginning January 2014, which was great news for all insurance beneficiaries with pre-existing conditions.

An illness or injury experienced before enrollment in a health insurance plan may be considered a pre-existing condition. Pre-existing conditions can include health issues such as cancer, diabetes, lupus, depression, acne, pregnancy, or just about any other health condition you can imagine.

Example: A 3/6 pre-existing clause means that any disabling condition which the Insured received treatment during the 3 months immediately prior to the effective date of coverage is excluded. Once the Insured has been covered for 6 months the pre-existing clause no longer applies.

Pre-Existing Condition: 3/6/12 Rule: If you are treated for a medical condition 3 months prior to your effective date, it will not be covered unless you are treatment free for 6 consecutive months after your effective date of coverage or after you have been insured and still active at work for 12 consecutive months.

(Health insurers may exclude coverage for pre-existing conditions for up to 12 months following the enrollment date.

What is the Waiver of Pre-Existing Medical Conditions in Travel Insurance? Simply put, the Waiver of Pre-Existing Medical Conditions covers, or “waives” the companies right to exclude pre-existing medical conditions from their policy.

All Medicare Supplement plans must contain which provision? Pre-existing conditions may be excluded from coverage for a maximum of 6 months.

A Medicare Supplement policy can't deny or limit coverage for a preexisting condition more than 6 months after effective date of coverage.