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.
· HMOs may not exclude coverage for pre-existing conditions. Instead, HMOs may impose an affiliation period before the health coverage begins.
· Other 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, children placed for adoption, or genetic information.
· Group health plans can only exclude coverage for pre-existing conditions for a limited time. The maximum period allowed for exclusion is 12 months. However, if you enroll late in a group health plan (after you were hired and not during a regular or special enrollment period), the rules are different depending on the type of plan you join.
If you seek to enroll late in a self-insured group health plan, your pre-existing condition exclusion cannot exceed 18 months.
If you seek to enroll late in a fully insured group health plan in Texas, the plan must either admit you immediately or admit you at the next open enrollment period. Fully insured group health plans must have at least one 31-day open enrollment period each year. If the plan admits you immediately, you may have a pre-existing condition exclusion period for up to 18 months. If the plan requires you to wait until the next open enrollment period, you may have a pre-existing condition exclusion period of up to 12 months.
· Group 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 insurance are considered creditable coverage.
· Coverage counts as continuous if it is not interrupted by a break of 63 or more days in a row.
In addition, in Texas, if you had a break in health coverage of more than 63 days in a row, and then enroll in a fully insured group health plan, that plan must give you credit for previous creditable coverage you had in effect at any time during the 12-month period preceding enrollment.
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.
· Your protections may differ if you move to a self-insured group health plan that offers more benefits than your old one did. Self-insured group health plans can look back to determine whether your previous 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. 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 group plans in Texas cannot use this method of crediting coverage.
· 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.