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.

• 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.
• If your pre-existing condition is newly diagnosed and you are entering a small group plan, you may have greater protections against a pre-existing condition exclusion period. Small group plans cannot apply a pre-existing exclusion period against a medical condition if that condition was identified for the first time during your prior continuous coverage, even if you were covered for less than 6 months.
• Pre-existing conditions can be excluded for different periods of time depending on the size of the group plan.

Under fully insured small group health plans, coverage for pre-existing conditions can be excluded for no longer than 6 months when you join the plan as a regular or special enrollee.  However, if you enroll late in a small group health plan (after you are hired and not during a regular or special enrollment period), you may have a 12-month pre-existing condition exclusion period.

Under self-insured group plans and fully insured large group plans, coverage for pre-existing conditions can be excluded for no longer than 12 months when you join the plan as a regular or special enrollee. However, if you enroll late, you may have a longer exclusion period.  Large group plans can impose an 18 month pre-existing exclusion period on late enrollees.

The maximum pre-existing condition exclusion period varies.

Health plan type                                                        Maximum exclusion period
Fully insured small group (regular enrollee)                             6 months
Fully insured small group (late enrollee)                                 12 months
Fully insured large group (regular enrollee)                            12 months
Fully insured large group (late enrollee)                                 18 months
Self-insured group health plan (regular enrollee)                    12 months
Self-insured group health plan (late enrollee)                         18 months

If you join a new group health plan, the law protects you from a new pre-existing condition exclusion period, provided you maintain continuous 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 of prior coverage, such as old health plan ID cards or statements from your doctor showing bills paid by your health insurance plan.

• The definition of continuous coverage varies depending if you are enrolling in a small group health plan or a large group health plan.

If you are enrolling in a fully insured small group plan then prior coverage is counted as continuous if it is not interrupted by a break of 90 or more days in a row.

If you are enrolling in a large group health plan or self-insured group health plan, prior coverage is counted as continuous if it is not interrupted by a lapse of 63 days or more in a row.

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.

What is continuous coverage?

You can get continuous coverage under one plan, or under several plans, as long as you don’t let your coverage lapse for a long time.

Art, who has diabetes, worked for 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 a small company called Beta Corporation.  He enrolled immediately in Beta’s fully insured small group health plan, which covers diabetes but imposes pre-existing condition exclusion periods.  In Rhode Island, fully insured small group health plans count as continuous all creditable coverage that is not interrupted by a lapse of more than 90 days. Therefore, because Art’s lapse in coverage was less than 90 days, Beta’s fully insured plan will credit his coverage at Ajax against any exclusion period.  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.  Therefore, in this case, Art’s prior coverage at Ajax will not be credited toward any exclusion period 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 his pre-existing condition exclusion period.

• 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 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. Plans that decide to measure your prior credible coverage in this way must notify you when you join the plan and use this approach for everyone.

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 group 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, Sue’s new 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.