Health Insurance Jargon Defined

Late enrollee
An individual who joins a group health plan on a date other than either a) the earliest date on which coverage can begin under the plan terms or b) on a special enrollment date. Under HIPAA, a late enrollee may be subject to a maximum preexisting-condition exclusion of up to 18 months.

MHPA
The Mental Health Parity Act is a federal law that requires health plans to provide mental health benefits that are equivalent to the plan’s medical benefits. MHPA applies only to employers with more than 50 employees.

Preexisting condition
An illness or condition that existed before the start of a person’s coverage under a group health plan.

Preexisting-condition exclusion
A limitation or exclusion of benefits for a condition that you had before your enrollment date in the group health plan. Under HIPAA, a preexisting-condition exclusion may only be applied if a) you had a significant break in coverage during the 12 months prior to your enrollment in the plan and b) received medical advice or treatment for the condition in the six months before your enrollment. The exclusion may not be longer than 12 months (18 months for a late enrollee).

Significant break in coverage
Generally, a significant break in coverage is a period of 63 consecutive days during which you have no creditable coverage. In some states, the period is longer if your plan coverage is provided through an insurance policy or HMO.

Special enrollment
Joining a group health plan when certain work or life events occur, regardless of the plan’s regular enrollment dates. Generally, special enrollment is available when you, your spouse, or your dependents lose other coverage; when you marry; or when you have a child. The plan must give you at least 30 days to request special enrollment.

Source: Adapted from the U.S. Department of Labor’s Health Benefits Advisor Glossary