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Group Health Plan Requirements

This page covers the following group health plan requirements under HIPAA:

  • Overview
  • Nondiscrimination Requirements
  • Special Enrollment Rights Provisions
  • Preexisting Condition Exclusion Prohibition

Overview

Under HIPAA, group health plans are subject to certain nondiscrimination, special enrollment, and preexisting condition requirements. These requirements are explained in detail below.

Nondiscrimination Requirements

Under HIPAA, an individual cannot be denied eligibility for benefits or charged more for coverage because of any health factor. However, distinctions among groups of similarly situated participants in a health plan may be permitted if they are based on bona-fide employment-based classifications consistent with the employer's usual business practice.

Health Factors

Under HIPAA, an individual cannot be denied eligibility for benefits or charged more for coverage because of any health factor. "Health factors" include:

  • Health status;  

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