CARD T206
Preexisting Condition
A health condition present before coverage begins. Whether it can affect coverage depends on the product and applicable law.
How it works
A preexisting condition existed before coverage began. ACA-compliant major medical coverage cannot reject an applicant, charge more because of health history, or exclude covered treatment merely because the condition is preexisting. Other products, such as disability income, some limited coverage, and certain Medigap situations, follow different rules. Identify the product before applying a rule. [10] [14]
A person diagnosed with asthma before enrolling in an ACA-compliant major medical plan cannot have covered asthma care excluded merely because it was preexisting.
Preexisting is a timing description, not automatic permission to deny coverage.
CARD T207
Guaranteed Issue
A requirement or feature allowing eligible applicants to obtain coverage without health-based rejection. Enrollment conditions and product rules still apply.
How it works
Guaranteed issue means eligible applicants can obtain coverage without health-based rejection, subject to the program’s enrollment conditions. It is different from guaranteed renewability, which concerns keeping existing coverage. Guaranteed issue does not mean free insurance, no benefit limits, or the right to enroll on any day. Product-specific guaranteed-issue windows can be important. [10] [14]
An eligible applicant enrolls during an allowed major medical enrollment period without being denied because of a medical history.
Guaranteed issue answers access at enrollment; guaranteed renewable answers continuation.
CARD T208
Open Enrollment
A scheduled period for enrolling in or changing coverage. The dates depend on the plan or program.
How it works
Open enrollment is a scheduled opportunity to elect or change coverage. Employer plans, the individual Marketplace, and Medicare use different windows and effective-date rules. Do not transfer one program’s dates to another. Missing the window can require waiting unless a special enrollment or other exception applies; Medicaid and CHIP enrollment are not limited to one annual open-enrollment window. [10]
An employee compares next year’s employer-plan choices during the employer’s announced annual election period.
Open enrollment is a window for election, not the same as the date coverage becomes effective.
CARD T209
Special Enrollment Period
An enrollment opportunity outside the usual window following an eligible event. Loss of qualifying coverage may create one.
How it works
A qualifying event can create a special enrollment opportunity outside annual open enrollment. Common events include loss of qualifying coverage, marriage, or gaining a dependent, subject to the program’s conditions. Marketplace windows often allow 60 days before or after qualifying events, depending on the event. Employer group-plan HIPAA rights commonly allow at least 30 days to request enrollment for specified events and 60 days for certain Medicaid/CHIP events. Voluntary cancellation or nonpayment does not automatically create a loss-of-coverage right. [10]
An employee loses qualifying spouse coverage and promptly requests special enrollment in the employer plan within the applicable deadline.
Event, program, deadline, and effective date must all match; an event is not unlimited permission to enroll forever.
APPLY THE TERMS
Practice questions
Select an answer, then check it to see why each option is right or wrong.
T206 · Preexisting Condition
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T207 · Guaranteed Issue
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T208 · Open Enrollment
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T209 · Special Enrollment Period
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Sources & further reading
Original explanations and practice scenarios informed by the following regulatory, legal, and product resources. State examples are not presented as nationwide deadlines or requirements.