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Determining Compliance with the HIPAA Provisions in Part 7 of ERISA

Limits on Preexisting Condition Exclusions - Six-Month Look-Back Period

Does the plan comply with the six-month look-back rule?

A preexisting condition exclusion may apply only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received during the 6-month period ending on an individual's "enrollment date." See ERISA section 701(a)(1); CFR 2590.701-3(a)(2)(i).

Definitions: An individual's enrollment date is the earlier of: (1) the first day of coverage; or (2) the first day of any waiting period for coverage. (Waiting period means the period that must pass before an employee or dependent is eligible to enroll under the terms of the plan. If an employee or dependent enrolls as a late enrollee or special enrollee, any period before such enrollment date is not a waiting period.) Therefore, if the plan has a waiting period, the 6-month look-back period ends on the first day of the waiting period, not the first day of coverage. See ERISA sections 701(b)(1) and (4); 29 CFR 2590.701-3(a)(3).

Tip: If the plan has a waiting period for coverage, ensure that the 6-month look- back period is measured from the first day of the waiting period, not the first day of coverage.