When you first enroll in a group health plan, the employer or insurance company may ask you questions to determine whether 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 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.

• 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 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.
• Under group health plans, coverage for pre-existing conditions can be excluded only for a limited time. The maximum period varies for different kinds of group plans. Also, if you enroll late in your group health plan (after you were hired and not during a regular or special enrollment period), you may have a longer pre-existing condition exclusion period up to 18 months. Ask your prospective employer if you are not sure what limit applies to you.

The maximum pre-existing condition exclusion period varies
Type/ Health Plan — Number of Employees – Maximum Exclusion Period
Fully Insured — 2-5 — 6 months (all enrollees)
Fully Insured — 6-50 – 0 months (regular and special enrollees)
                                 6 months (late enrollees)
Fully Insured — 51+ – 12 months (all enrollees)
Self-funded  — any size – 12 months (regular and special enrollees)
                                     18 months (late enrollees)

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

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  • 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. In the large group market, coverage counts as continuous if it is not interrupted by a break of 63 or more days in a row. In the small group market, coverage cannot be interrupted by 90 days.

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 95 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 and HMO affiliation periods do not count as breaks 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 health plan did. Group health 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 group health plan may impose a pre-existing condition exclusion period for that category.

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-funded health plan does cover prescription drugs.  However, because her prior policy did not, the new plan refuses to cover her blood pressure medicine for a year.

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.