California Group Health
Insurance Pre-Existing Condition
and New Hire Waiting Periods
Once a Small Business in
California offers new group
health insurance to its
employees, one of the first
questions out of the mouth of
the employee newly enrolling is
‘what about any pre-existing
conditions I may have?”
Immediately after that we hear,
“will I have to wait several
months to enroll in the health
plan or does it automatically
start right away?” It is a fair
concern for you to have and the
answers are not the same: they
can be very dependent on the
company and the health insurance
benefits package offered.
Pre-Existing Condition
Waiting Period Clauses
In California, for Small
Business groups size 2-50
employees can face waiting
periods for coverage specific to
pre-existing conditions only.
Treatment for all new
conditions, expenses, accidents,
etc.. would still be covered
even in enrollments where a
pre-existing condition waiting
period applies. A pre-existing
condition waiting period is
waived when you have prior
coverage in the last 6 months
leading up to the effective date
of the new coverage, and the
prior coverage does not
terminate beyond 62 days prior
to the start date of the new
plan. If you had coverage for
only partially of the 6 months
time frame then you’ll receive a
reduced waiting period
subtracting the number of months
coverage existed. More
information can be found in our
section on Small Group
Underwriting. The
California Small Group health
insurance carrier will verify
the existence of coverage
through a variety of means such
as:
-copies of employee id cards
-most recent paycheck stub
reflecting health insurance
premium deduction
-certificate of creditable
coverage from prior carrier
reflecting enrollment period
-carrier billing statement
submitted by the employer group
Failure to provide these
documents at the point of
enrollment can delay the
enrollment’s effective date. It
can also lead to getting wrongly
assigned to a pre-existing
condition waiting period when it
really should not be in place.
Then you are stuck with getting
claims overturned and providing
your evidence of coverage
certificate to get your waiting
period waived.
New Hire Waiting
Periods When
you start your new coverage are
you always able to enroll right
away? The answer is no. It’s
possible to start right away
(which typically means 1st
of the month following date of
hire). With Small Group health
insurance offers you can face a
waiting period of zero to 6
months following 1st
of the month after date of
hire. Once this enrollment
takes place you will still face
a pre-existing condition waiting
period if you had no health
insurance coverage in the last 6
months. You can read more
about Employer imposed new hire
waiting periods in our section
on Understanding your
Small Business health insurance
Employer application.
Exclusions to the
pre-existing condition waiting
period
There are medical
conditions which do not apply to
the pre-existing condition
waiting period. Maternity, for
instance, typically will get the
waiting period for treatment
waived automatically. Health
Maintenance Organizations or HMO’s
also will usually waive any
pre-existing condition waiting
periods because they are going
to control the treatment of the
member regardless.
Other
important
resources:
California
Small Group
health quote
California
Small Group
online
doctor
listing
California
Group
Enrollment
and
Eligibility
Center
