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.

  • 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 is called the look back period.
  • 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 plan can exclude coverage for pre-existing conditions only for a limited time. The maximum period is 12 months. However, if you enroll late in a group health plan (after you are hired and not during a regular or special enrollment period), you may have an 18-month pre-existing condition exclusion period. In Tennessee, fully insured group health plans can refuse to enroll late enrollees for up to 18 months, apply an 18-month pre-existing condition exclusion period, or apply some combination of both, which together lasts no more than 18 months. A plan must treat all its late members the same, whichever method it chooses to apply.
  • Group health plans that impose pre-existing condition exclusion periods must give you credit for any previous continuous creditable coverage. Most types of private and government sponsored health coverage are considered to be creditable coverage. Coverage counts as continuous if it has not been interrupted by a break of 63 or more days in a row.

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.

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 have a lapse between plans 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.  He began working for Charter Company the day after he left Beta. 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 towards the 12-month exclusion period.

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 only credit coverage 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 in coverage of more than 63 consecutive days.

  • 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 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 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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