Can a Group Health Plan Limit My Coverage for Pre-existing Health Conditions?

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When you first enroll in a group health plan, the employer or insurance company may ask if you have any pre-existing conditions. Or, if you make a claim during the first year of coverage, the plan may look back to see whether it was for such a condition. If so, it may try to exclude coverage for services related to that condition for a certain length of time. However, federal and state laws protect you by placing limits on these pre-existing condition exclusion periods under group health plans. In some cases your protections will vary, depending on the type of group health plan.

· A group health plan can count as pre-existing conditions only those for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice within the 6 months immediately before you joined that plan. This period is also called the look back period.

· Group health plans cannot apply a pre-existing condition exclusion period for pregnancy, newborns or newly adopted children, children placed for adoption, or genetic information.

· Coverage for pre-existing conditions can be excluded under group health plans only for a limited time. The maximum period is 12 months. However, if you enroll late in a group health plan (after you were hired and not during a regular or special enrollment period) you may have a pre-existing condition exclusion period of up to 18 months.

· Group health plans that impose pre-existing condition exclusion periods must give you credit for any previous continuous creditable coverage that you’ve had. Most types of private and government-sponsored health insurance are considered creditable coverage.

What is creditable coverage?

Most health insurance counts as creditable coverage, including:

Children’s Health Insurance Program               Medicare

Federal Employees Health Benefits(FEHBP)       Military health coverage
Foreign National Coverage                                  (CHAMPUS, TRICARE)

Group health plan (including COBRA)               State high-risk pools

Indian Health Service                                   Student health insurance
Individual health insurance                            VA coverage

In most cases, you should get a certificate of creditable coverage when you leave a health plan. You also can request certificates at other times. If you cannot get one, you can submit other proof of prior coverage, such as old health plan ID cards or statements from your doctor showing bills paid by your health insurance plan.

· Coverage counts as continuous if it is not interrupted by a significant break. The definition of continuous coverage varies depending on the type of group health plan you are joining. If you are joining a fully insured group health plan, coverage counts as continuous if it is not interrupted by a break of 90 or more days in a row. If you are joining a self-insured group health plan, coverage counts as continuous if it is not interrupted by a break of 63 or more days in a row.

Fully insured and self-insured group health plans count continuous coverage differently.

Art, who is diabetic, worked for the Ajax Company and was covered under its group health plan for 18 months. He lost his job and was without coverage for 75 days. Fortunately, on the 76th day after leaving Ajax, Art found a new job at Beta Corporation. He enrolled immediately in Beta’s fully insured group health plan, which cover care for diabetes but requires a pre-existing condition exclusion period. In Georgia, fully insured group health plans count as continuous all creditable coverage that is not interrupted by a lapse of 90 consecutive days or more. Therefore, because Art’s lapse in coverage was less than 90 days, he will get credit for his coverage at Ajax. Beta’s plan will begin paying for Art’s diabetes care immediately.

Now consider a slightly different situation. Assume Beta Corporation’s group health plan is self-insured. Self-insured plans must count as continuous all creditable coverage that is not interrupted by a break of 63 or more consecutive days. In this case, Art will not get credit for his prior coverage at Ajax because it was followed by a break greater than 63 days. Beta’s plan will begin paying for Art’s diabetes care at the end of the exclusion period.

· In determining continuous coverage, employer-imposed waiting periods and HMO affiliation periods do not count as a break in coverage. If your new plan imposes a pre-existing condition exclusion period, you can credit time under your prior continuous coverage toward it. If your employer requires a waiting period, the pre-existing condition exclusion period begins on the first day of the waiting period. HMOs that require an affiliation period cannot exclude coverage for pre-existing conditions.

· Your protections may differ if you move to a group health plan that offers more benefits than your old one did. Plans can look back to determine whether your previous plan covered prescription drugs, mental health, substance abuse, dental care, or vision care. If you did not have continuous coverage for one or more of these categories of benefits, your new group health plan may impose a pre-existing condition exclusion period for that category. Plans that use this method of crediting prior coverage must use it for everyone and must disclose this to you when you enroll.

Even if coverage is continuous, there may be an exclusion for certain benefits

Sue needs prescription medication to control her blood pressure. She had 2 years of continuous coverage under her employer’s group health plan, which did not cover prescription drugs. Sue changes jobs, and her new employer’s fully insured plan does cover prescription drugs. However, because her prior policy did not, the new plan refuses to cover her blood pressure medicine for 6 months.

Question: Is this permitted?

Answer: Yes. However, the plan must pay for covered doctor visits, hospital care, and other services for Sue’s high blood pressure. It also must pay for covered prescription drugs she needs for other conditions that were not pre-existing.

· No pre-existing condition exclusion period can be applied without appropriate notice. Your group health plan must inform you, in writing, if it intends to impose such a period. Also, if needed, it must help you get a certificate of creditable coverage from your old health plan.

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