HIPAA regulations for pre-existing conditions?

[Guest pokymike49]

Per HIPAA regulations, in order to trigger a pre-existing conditions exclusion, medical care provided during the 6 month look-back period can only be considered if it is provided by a state(i.e., the 50, as well as US territorities) licensed physician. Does that mean that medical care provided in a foreign country by a non-state licensed physician cannot be utilized for the purpose of establishing a pre-existing condition, and triggering a pre-existing conditions exclusion?

[Guest chloe]

This is an excellent question. I can't find anything in the regulation or preamble allowing a plan to consider a diagnosis or treatment obtained from a non-US licensed physician. Plans often cover employees in Canada and other countries. This is a problem that should be raised to the Dept. of Labor for their interpretation. Unfortunately, I'm not able to do that in my position. Can someone raise this issue to the Dept?

[GBurns]

I thought that HIPAA pre-existing conditions exclusions etc required "creditable coverage" rather than any particular service provider.

Where did you find mention in either state or Federal HIPAA of pre-exs being conditioned by the licensing of the service provider?

[Guest pokymike49]

Section 2590.701.3 (a) [2] General rules: Subject to paragraph of this section, a group health plan, and a health insurer offering group health insurance coverage, may impose, with respect to a participant or beneficiary, a preexisting condition exclusion only if requirements of this paragraph (a) [2] are satisfied.

(i) 6-month lookback rule A preexisting condition exclsuion must relate to a condition (whether physical or mental) regardless of the cause of the condition for which medical advice, diagnosis, care or treatment was recommended or received within the 6 month period ending on the enrollment date.

(A) For the purpose of paragraph (a)(2)( i), medical advice. diagnosis, care or treatment is taken into account only if it is recommended by, or received from, an individual licensed or similarly authorized to provide such services under State law and operating within the scope of practice authorized by State law.

(Federal Register / Vol. 69, No. 250 / Thursday, December 30, 2004 / Rules and Regulations, p. 78765)

"State" is defined in Sec. 2590.701-2 as "each of the several states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

(Ibid. p.78764)

[GBurns]

Thank you.

But the fact that someone had medical care from whatever source has nothing to do with a pre-existing condition, by and of itself. There are other factors to be considered.

If I had Cancer, and went to Mexico for some experimental treatment, according to the cite that you gave, that treatment would not count. BUT, the fact that I had Cancer could depending on other facts. So the treatment by whatever source might be irrelevant in many cases.

[J2D2]

GBurns,

I think it's a 2-pronged test. First, the individual must have a pre-existing condition. Second, the individual must have received treatment for that condition within 6 months prior to becoming covered. For example, I might have had cancer or some other condition for a year and not have known it. In that situation, the pre-ex exclusion would not apply if I didn't receive treatment during the 6 months preceding my entry into the plan. In the situation you posit, if the only treatment I received within the 6 month period was in Mexico, the reg seems to indicate that the pre-ex exclusion could not be applied.

[GBurns]

Agreed.