Certified Revenue Cycle Representative (CRCR) Practice Exam

What does a pre-existing condition limitation restrict?

1. Payments for new medical conditions

2. Payments for ongoing health maintenance

3. Payments for charges resulting from pre-existing health conditions

4. Payments for preventive services

The correct answer is: Payments for charges resulting from pre-existing health conditions

A pre-existing condition limitation specifically restricts payments for charges resulting from health conditions that existed prior to the start of a new health insurance policy. This means that if an individual has a medical issue that they were diagnosed with or had received treatment for before enrolling in a new insurance plan, that plan may not cover costs related to that condition for a specified period or at all. This type of limitation is put in place by insurance providers to mitigate financial risk, as covering ongoing costs for pre-existing conditions can be costly and adversely impact the insurer's financial stability. Typically, insurers may impose a waiting period or outright exclusions related to treatment for these conditions to ensure that they are not disproportionately burdened by claims from individuals seeking coverage for existing issues. While the other options touch on important aspects of health insurance coverage, they do not pertain to the core definition of a pre-existing condition limitation. The restriction particularly involves charges pertinent to those existing conditions rather than new medical conditions, health maintenance, or preventive services, which can have different coverage rules and certain protections under legislation like the Affordable Care Act.