Maryland Life and Health Insurance License Practice Exam

Under HIPAA, what is required for a group health plan to not impose a pre-existing condition exclusion?

1. At least 6 months of prior coverage

2. At least 12 months of creditable medical coverage

3. Immediate enrollment upon leaving a previous plan

4. Proof of good health

The correct answer is: At least 12 months of creditable medical coverage

A group health plan cannot impose a pre-existing condition exclusion if an individual has at least 12 months of creditable medical coverage. This requirement stems from the Health Insurance Portability and Accountability Act (HIPAA), which was designed to improve the portability and continuity of health insurance coverage. When individuals transition from one health insurance plan to another, having a history of at least 12 months of credible coverage ensures that they are not penalized for prior health issues when enrolling in a new plan. This standard is in place to protect individuals from being denied coverage or facing exclusions based on their medical history, thus promoting fair access to healthcare. The emphasis is on ensuring continuity of care and preventing gaps in health insurance that could lead to unintentional loss of coverage, particularly for those with existing health conditions. Other options do not meet the criteria established under HIPAA for avoiding pre-existing condition exclusions. For example, prior coverage for only 6 months or immediate enrollment are not sufficient on their own without the required period of creditable coverage. Similarly, proof of good health is unrelated to the requirements under HIPAA regarding pre-existing conditions and does not guarantee eligibility for benefits under a new plan.