Group Health Plans and Pre-Existing Conditions in California
The rules about pre-existing conditions for group health plans can be extremely confusing. If you don’t know insurance jargon and current laws related to healthcare, it can feel like the insurance company holds your life in its hands. As a consumer, you can take back control of your healthcare by learning how pre-existing conditions work and what California and federal laws have to say about group health plans and pre-existing conditions.
The Dreaded Pre-Existing Condition
Thanks to the federal government’s Health Insurance Portability and Accountability Act HIPAA pre-existing conditions aren’t as devastating as they once were. Currently, a pre-existing condition is any health problem that required medical treatment or advice during a six-month period immediately prior to the start of your new health insurance plan.
What is NOT Pre-Existing
- If you have a diagnoses of a condition, like rheumatoid arthritis, but did not seek medical care or advice of any kind for that condition for 6 months or longer, it cannot be considered a pre-existing condition.
- Pregnancy is not considered pre-existing even if you change insurance plans before delivery or did not have insurance coverage upon conception.
- Having a family history of a condition, or having a known genetic marker for a certain disease does not make that disease pre-existing as long as you have not shown symptoms of the disease and have not sought treatment for those symptoms.
HIPAA and Your Group Health Plan
Under the new HIPAA laws, all of your current (and future) health conditions are protected from pre-existing exclusion if you change jobs or health plans. You can go without health insurance for a total of 63 days before the rules change.
After a break of 63 days or more from health insurance, anything you sought medical treatment or advice for in the six months immediately before the date you apply for reinstatement of health insurance may be considered pre-existing.
California Law and Your Group Health Plan
Under California law AB 1672, the federal government’s 63 days is extended to 180 days without health insurance before you are considered to have experienced a significant break in coverage, giving you more time to obtain health insurance.
Pre-Existing Time Limits
Even if your new group health plan has ruled that you have a pre-existing condition (or several) there’s no need to panic. HIPAA and the state of California come to your rescue.
HIPAA limits the amount of time a group health plan can exclude payment for a pre-existing condition. Under HIPAA, the maximum amount of time is 12-18 months; 12 months if you enrolled for a group health plan as soon as you were eligible, 18 months if you were a later enroller.
Under California law, you have even more protection from group health plans and pre-existing conditions. The state legislature limits the pre-existing exclusionary period to a maximum of 6 months for certain conditions California law AB 1672. That means you may have to pay for medical expenses related to your pre-existing condition for six to twelve months, but the group health plan must reinstate full benefits after that time.
Waiting It Out
If you find yourself waiting out a pre-existing exclusionary period, you should know there are ways to reduce your exclusionary time.
- Enroll for a group health plan as soon as you are eligible. Signing up late extends your exclusionary period.
- Some consumers can use prior continuous medical coverage as credit towards an exclusionary period. You can find out more about pre-existing condition exclusionary credit from the California disability benefits website.
- Know your rights. According to California Health and Safety Code sections 1357.06 and 1357.51(a), an employer with 2-50 employees who extends group health plan insurance and has any health care service plan contract that covers three or more enrollees can only deny coverage for a preexisting condition for a total of six months following the effective date of coverage under the new health plan. The HIPAA enforced twelve-month exclusion period may be applied, however, if you enrolled after the enrollment deadline, or if your plan covers only one or two individuals and is not an employer-sponsored plan.
Group health plans and pre-existing conditions can be complicated, but knowing your rights and deciphering the jargon can help you get the most from your group health insurance plan. Be sure to check out our other health insurance information, tips, and news to learn more about your health insurance coverage.