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 seek to exclude coverage for services related to that condition for a certain length of time.  However, federal and state law protects you by placing limits on these pre-existing condition exclusion periods under group health plans.

• A group health plan can count as pre-existing conditions only those for which you actually received (or were recommended to receive) a diagnosis or treatment during the 6-month period immediately before you joined that plan. This period is called a 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.
• Under group health plans, coverage for pre-existing conditions can generally be excluded only for no longer than 12 months. However, if you enroll late in your group plan (after you were hired and not during a regular or special enrollment period), you may have an 18 month pre-existing condition exclusion period.
• 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 coverage are considered creditable coverage.

What is creditable coverage?

Most health insurance counts as creditable coverage, including:
Children’s Health Insurance Program                             
Federal Employees Health Benefits (FEHBP)                
Foreign National Coverage  
Group health plan (including COBRA)                            
Indian Health Service
Individual health insurance
Medicaid
Medicare
Military health coverage(CHAMPUS,TRICARE)
State high-risk pools
Student 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, 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. In the group market, coverage counts as continuous if it is not interrupted by a break of 63 or more days in a row.

What is continuous coverage?

You can get continuous coverage under one plan, or under several plans as long as you don’t have a lapse of 63 or more consecutive days.

Take Art, who has diabetes.  Ajax Company covered him under its group health plan for 9 months, but he lost his job and health coverage.  Then, 45 days later, Art found a new job at Beta Corporation and had health coverage for 9 more months.  Art changed jobs again.  His new company, Charter, has a health plan that covers care for diabetes but excludes pre-existing conditions for 12 months. Charter must cover Art’s diabetes care immediately, because his 18 months of prior continuous coverage are credited against the 12-month exclusion.

Now consider a slightly different situation.  Assume Art was uninsured for 90 days between his jobs at Ajax and Beta.  In this case, Charter will credit coverage only under Beta’s plan toward the 12-month pre-existing condition exclusion period. Charter’s plan will begin paying for Art’s diabetes care in 3 months (1 year minus 9 months).  Art does not get credit for his coverage at Ajax since he had a break of more than 63 consecutive days.

In determining continuous coverage, employer-imposed waiting 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.

• 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.