Pre-existing conditions frequently asked questions
What kind of proof do I need to show my new plan in order to reduce my exclusion period?
To make a determination on your exclusion period, plans generally need to receive information about your creditable coverage from a certificate provided by your prior insurance company or HMO.
The insurance company or HMO must automatically give you a certificate of creditable coverage when you lose coverage under the plan. They must also provide you with a certificate if you become entitled to elect COBRA-continuation coverage, and when your COBRA-continuation coverage ends.
You also have the right to request and receive a certificate from your previous insurance company or HMO within 24 months after your coverage ends.
I want to buy an individual health insurance policy. Can the insurance company deny me a policy or exclude pre-existing conditions from my coverage?
Yes. The company can reject your application if you do not qualify for an exemption and your health history is poor. All insurers require consumers seeking individual health coverage to complete the Standard Health Questionnaire. See the questionnaire for list of exemptions (PDF, 164KB) (www.wship.org).
The company can also require a nine-month pre-existing-condition exclusion period in its coverage. The company must also reduce its pre-existing-condition waiting period for certain prior health insurance coverage. For more information on the unique rules of individual plans, see our section on individual health care coverage.
NOTE: Currently, health reform prevents all insurers from denying coverage to children under age 19 due to health issues. Starting Jan. 1, 2014, health insurers will no longer be able to deny coverage to anyone due to health issues.
My employer has a waiting period that must pass before I can enroll in the company’s health plan. How does the employer-imposed waiting period affect the plan’s pre-existing-condition exclusion period?
Federal law allows employer-sponsored group health plans to impose a waiting period before coverage takes effect. A waiting period is the period that must pass before an employee or a dependent is eligible to enroll under the terms of the plan.
Some plans have both an employer-imposed waiting period and a pre-existing-condition exclusion period.
If a group health plan has both an employer-imposed waiting period and a pre-existing-condition exclusion period, then federal HIPAA law requires that the pre-existing-condition exclusion period begin at the same time the employer-imposed waiting period starts.
For example, typically your first day of work is the start of your employer-imposed waiting period. If you start work Jan. 1, 2013, and the plan has a one-month employer-imposed waiting period before coverage goes into effect, then your coverage would begin Feb. 1, 2013.
If the group health plan has a three-month pre-existing-condition exclusion period, this period would end March 31, 2013, two months after your plan’s effective date.
The health plan would have to give you credit for the month of January because the employer-imposed waiting period and the pre-existing-condition exclusion period must run concurrently.
Starting Jan. 1, 2014, under health reform, health insurers will no longer be able to deny coverage to anyone due to health issues. In addition, health reform will also limit the employer-imposed waiting period to 90 days.
With health reform, will pre-existing conditions still apply?
No. Starting Jan. 1, 2014, federal health reform prevents all health insurers from denying coverage to anyone due to health issues.