Pre-Existing Condition Exclusions - Frequently Asked Questions 

The Affordable Care Act's (ACA) pre-existing condition exclusion provision prohibits health insurers and employers that provide insurance coverage from denying coverage to individuals because of a pre-existing condition. Pre-existing condition exclusions were eliminated for children (under age 19) beginning in September 2010. This provision of ACA expanded in 2014 - it goes into effect for all enrollees as of the first plan or policy year on or after Jan. 1, 2014. It applies to ALL group plans.

A pre-existing condition exclusion means a limitation or exclusion of benefits (including a denial of coverage) based on the fact that the condition was present before the effective date of coverage (or if coverage is denied, the date of the denial) under a group health plan. The limitation or exclusion is not dependent on whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that day.

Q What changes in 2014?
A As of the first plan or policy year on or after Jan. 1, 2014, health plans are required to eliminate pre-existing condition exclusions for individuals of all ages. This applies to both non-grandfathered and grandfathered group health plans.

Q Are grandfathered plans exempt from the pre-existing condition exclusion provision of ACA?
A It applies to both grandfathered and non-grandfathered group health plans.

Q When does this provision go into effect?
A The pre-existing condition exclusion is effective as of the first plan or policy year on or after Jan. 1, 2014.

Q Since pre-existing condition exclusions will no longer be permitted beginning on the first plan or policy year on or after Jan. 1, 2014, will Certificates of Creditable Coverage (COCC) still be sent in 2014?
A Yes, COCC letters will still be sent in 2014. Insurers are required by law to provide certificates in certain situations, such as when an individual loses coverage under a plan. This requirement is still in effect today.