Jul 18, 2005
I am unclear about the pre-existing condition clause. If you test HIV positive before the open enrollment period of a future employer: 1. Can you be denied any coverage at the time of open enrollment? 2. Can your future insurance provider refuse to pay for any infections or medications that are HIV related? I am in a name based reporting state and fear that no future illnesses would be covered if I am documented as HIV positive before I start a job.
| Response from Ms. Franzoi
A pre-existing condition clause is an exclusion for treatment for a particular health condition for a period of time (usually 12 months) because you had the condition and received treatment for it during a period of time (usually 90 days) prior to coverage commencing. It applies when you initially apply for coverage not during open enrollment. Pre-exisitng condition clauses are governed by federal law (HIPAA). Under HIPAA, a group health plan cannot have a pre-exisitng condition exclusion period for longer than 12 months. This means that the longest time treatment for a particular condition can be excluded is 12 months. Furthermore, if a plan has a pre-existing exclusion clause, it must recognize prior periods of health coverage towards this exclusion unless you had a break in coverage of greater than 63 days.
In your case, if you were to become covered under a new plan (because you changed jobs not due to open enrollment) that had a pre-existing condition clause, it would not apply to you if you had been covered under another plan for at least 12 months and had not had a break in coverage of greater than 63 days. A pre-existing condition clause only applies to the medical condition that is considered pre-exsiting not to other illnesses.
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