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 you belong to.

  • Group health plans 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 a specific period immediately before you joined that plan or before the start of the waiting period. This period is also called the look back period. The amount of time a group health plan can look back varies depending on the type of plan you join. If you are joining a fully-insured group plan, the maximum look back period is 3 months. If you are joining a self-insured group plan, the maximum look back period is 6 months.
  • Group health plans can only exclude coverage for pre-existing conditions for a limited time. The maximum exclusion period depends on the type of group health plan you are joining. If you are joining a fully insured group health plan in New Hampshire, the maximum exclusion period is 9 months. If you are joining a self-insured group health plan, the maximum exclusion period is 12 months. If you enroll late in your group health plan (after you are hired and not during a regular or special enrollment period), your pre-existing condition exclusion period cannot exceed 18 months.
  • Group health plans cannot apply a pre-existing condition exclusion period for pregnancy, newborns, newly adopted children, children placed for adoption, or genetic information.
  • Group health plans that impose pre-existing condition exclusion periods must give you credit for any previous continuous creditable coverage that you have 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
Federal Employees Health Benefits (FEHBP)
Foreign National Coverage
Group health plan (including COBRA)
Indian Health Service
Individual health insurance
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.

  • Health coverage counts as continuous if it is not interrupted by a significant break of 63 days or more in a row. The new coverage must be in place on the 63rd day in order to avoid any pre-existing condition exclusion periods.

What is continuous coverage?

You can get continuous coverage under one plan, or several plans, as long as you don’t have a lapse of 63 or more 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 self-insured 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 - 9 months).  Art does not get credit for his coverage at Ajax since he had a break in coverage of 63 or more consecutive days.  However, if Charter offered a fully insured group health plan, Art’s diabetes care coverage would begin immediately because fully insured group health plans in New Hampshire must disregard a lapse in coverage due to unemployment.

  • 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, the plan must 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. In addition, if you were unemployed and uninsured prior to enrolling in a fully insured group health plan in New Hampshire, but had coverage before you were unemployed, the gap in coverage you experienced during your period of unemployment shall not count as a break in coverage.
  • Your protections may differ if you move to a fully insured large group health plan or a self-insured group health plan that offers more benefits than your old one did. These plans can look back to determine whether your previous health 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 self-insured group health plan may impose a pre-existing condition exclusion period for that category. Group plans that use this method of crediting prior coverage must use it for everyone and must disclose this to you when you enroll. Fully insured small group health plans in New Hampshire do not use this method of crediting coverage.

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 self-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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