Can plans exclude or limit benefits for certain conditions or treatments?
Group health plans may exclude coverage for a specific disease, limit or exclude benefits for certain types of treatments or drugs, or limit or exclude benefits based on a determination that the benefits are experimental or medically unnecessary – but only if the benefit restriction applies uniformly to all similarly situated individuals and is not directed at individual participants or beneficiaries based on a health factor they may have. (Plan amendments that apply to all individuals in a group of similarly situated individuals and that are effective no earlier than the first day of the next plan year after the amendment is adopted are not considered to be directed at individual participants and beneficiaries.) Compliance with HIPAAs nondiscrimination provisions does not in any way reflect compliance with any other provision of ERISA (including COBRA and ERISAs fiduciary provisions). Nor does it reflect compliance with other State or Federal laws (such as the Americans with Disabilit
