July 29, 2010

Pre-Existing Condition Exclusions for Children Under 19 Regulations Clarified

The Department of Health and Human Services (HHS) recently published the interim final regulations restricting insurers from imposing pre-existing condition exclusions on children under the age of 19. Health insurance issuers must guarantee issue of coverage for children under age 19 in both the group and individual markets, beginning on or after Sept. 23, 2010.  These regulations apply to grandfathered group health plans and new group health insurance coverage. It does not apply to grandfathered individual health insurance coverage that was in existence on March 23, 2010. The regulation does apply to non-grandfathered individual health insurance policies. 

Guarantee issue of coverage for children under age 19, in the individual market (whether family or individual coverage) is limited to annual enrollment periods, if allowed under State law. If no state law exists, then health plans may determine the number and duration of enrollment periods. HHS and states will monitor the policy and if they determine there are not sufficient enrollment periods, further guidance will be issued. 
The new guidance also made clear:

  • Medicaid and Children’s Health Insurance Program (CHIP) may not “inappropriately” transfer children under age 19 to the individual market. The Administration will enforce its current policies on premium assistance and consider new ones if evidence emerges that children with pre-existing conditions are being diverted inappropriately from Medicaid or CHIP to private insurance plans that newly offer guaranteed issue to children regardless of their health status.
  • Child-only insurance plans in force in the individual market on March 23, 2010 that do not significantly change their benefits, cost sharing, and other features, will be “grandfathered” or exempt from these regulations. 

The information on this website is based on BCBSLA’s review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.