Health care reform update - May 2014
90-day and Pre-Existing Condition Exclusions Waiting
Periods
Background
There has been some confusion about two upcoming parts of the Affordable Care Act (ACA, or health care reform
law):
1.
When pre-existing exclusions and/or waiting periods go away for all people
2.
When the 90-day waiting period kicks in, what it means for people in a waiting period, and who needs to
manage the waiting period
It is very important to note that there is no “opt-out” or exception for either of these rules for fully-insured or selffunded (ASO) groups, no matter what size and if they are grandfathered and non-grandfathered.
Pre-existing conditions
For groups new and renewing on and after September 23, 2010, pre-existing (pre-ex) condition exclusions and/or
waiting periods went away for children ages 0 through 19. In 2014, they go away for everyone. For groups renewing
in 2014, pre-existing condition exclusions and/or waiting periods go away at the group’s renewal date. This means
that even if a person is in a pre-existing condition waiting period when the group renews, they do not have to wait it
out. If a group renews on July 1, 2014, the pre-existing condition exclusion waiting period goes away for all people
in that group on July 1. For new groups that go into effect on or after January 1, 2014, pre-existing condition
exclusion waiting periods will not exist.
90-day waiting period
On February 20, 2014, the Department of Labor put out the final rules for the 90-day waiting period and added a
proposed rule for “reasonable and bona fide employment-based orientation period.” The 90-day waiting period rules
are in effect now, and employers can rely on the orientation period rules.
Note: 90 days is counted as calendar days, not work days. Coverage must start on the 91 st day, not the first
of the month following a 90-day waiting period.
The 90-day waiting period starts after the worker has met the group health plan’s terms for joining the health plan.
These terms may include:
• Being in a job class that is offered benefits
• Getting a required license to do the job (as listed in the group health plan’s terms)
• After a time of “reasonable and bona fide employment-based orientation”
o Limit to the orientation period is one month, meaning one calendar month minus one day.
o The waiting period must begin on the next calendar day after the orientation period ends
 Example 1: Worker starts on May 3; orientation period has to end on June 2. The 90-day
waiting period starts on June 3.
 Example 2: Worker starts on January 30; orientation has to end on February 28 (29 if a
leap year). The 90-day waiting period starts on March 1.
 Example 3: Worker starts on August 31; orientation has to end on September 30. The
90-day waiting period starts October 1.
If a worker is already in a 90-day waiting period that is longer than 90 days when the group renews, the group needs
to make sure that the worker’s waiting period is not more than 90 days from the date the waiting period started.
Example 1: Group health plan A is a calendar year plan, meaning the plan year starts on January 1 and ends on
December 31. Before January 1, 2014, the group has a 6-month waiting period. Worker A starts work as a full-time
worker on October 1, 2013, and so does the 6-month waiting period. As of January 1, 2014, Group health plan A
cannot make a worker wait more than 90 days from date of hire for coverage, so Worker A is able to sign up for
coverage that starts on January 1, 2014, ending the waiting period.
Example 2: Group health plan B has a plan year that starts on July 1 and ends on June 30. Group B has a 120-day
waiting period. Worker B starts work as a full-time worker on May 1, 2014, and so does the 120-day waiting period.
When Group health plan B renews on July 1, 2014, the waiting period has to be cut to 90 days, so Worker B will be
able to sign up for coverage that starts on or before July 29 (90 calendar days from the day of hire).
An employer can tell us what their waiting period is and we will use that information. This is allowed by the law.
See the chart below for a side-by-side chart of the rules and waiting periods.
Description
Pre-existing Condition Waiting Periods
Eligibility Waiting Periods
Part of a benefit plan that limits or does not
cover health conditions that a person had before
his or her coverage start date in a new health
plan.
The number of days or months a business says
a new worker has to wait from his or her hire
date until health coverage starts.
For groups with an effective date on or after
1/1/2014, pre-existing condition waiting periods
will not be allowed.
ACA Requirement
For groups renewing on or after 1/1/2014, preexisting condition exclusions will go away on the
group’s renewal date.
• Workers in a pre-existing condition
exclusion waiting period when the group
renews get coverage for the pre-existing
condition starting the date the group
renews.
For plan years beginning on or after 1/1/2014,
group health plans cannot make any person
wait more than 90 calendar days for health
coverage to start.
At renewal, employers that have waiting periods
need to tell us what their waiting period is.
This content is provided solely for informational purposes. It is not intended as and does not constitute legal advice. The information contained herein should not
be relied upon or used as a substitute for consultation with legal, accounting, tax and/or other professional advisers.
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