Wednesday, November 25, 2009

How will the ‘‘Affordable Health Care for America Act’’ treat pre-existing conditions?

The Act removes the current “look-back” timeframe of 6 months and replaces it with a 30-day look-back period. In addition, the Act reduces the exclusionary period from the current 12 to 3 months. Furthermore, the Act reduces the 18-month exclusionary period in the case of late enrollees to 9 months. This, obviously, shortens the time period that a plan can review the individual’s prior medical history for possibly pre-existing conditions and lessens the future time period the plan can use to exclude coverage for pre-existing conditions that occurred prior to an individual’s enrollment into the plan. However, once a health care plan is subject to § 211 of the Act all application of pre-existing conditions are prohibited. Most group health care plans will be subject to § 211 on January 1, 2010, certain exceptions apply for collectedly bargained plans.

The Act specifically notes that group and individual plans may not treat “domestic violence” as a pre-existing condition for any plan “offered, sold, issued, renewed, in effect, or operated” on or after January 1, 2010.

The Act prohibits, group and individual health care plans that offer surgical benefits, from denying coverage and treatment of a “minor child’s congenital or developmental deformity or disorder”. For the purposes of this provision, a minor child is any otherwise dependent child under the age of 21. However, the Act does exclude cosmetic surgery used to alter a normal body structure to “improve appearance or self-esteem”.

The Act prohibits the imposition of “aggregate dollar lifetime limits” on payable benefits for members and their dependents of group and individual health care plans. This provision is effective for plan years beginning on or after January 1, 2010.