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Understanding the ACA's 90-Day waiting period

In March, the Affordable Care Act (ACA) issued a proposed regulation that excludes group health plans and carriers offering group health insurance coverage from applying any waiting period that exceeds 90 calendar days.


A waiting period is defined as the period of time that must pass before an individual and any dependents are eligible to be covered for plan benefits.


According to the new ACA proposed regulation, any plan years that begin on or after Jan. 1, 2014, are not allowed to make full-time employees who are eligible for benefits in group health plans wait longer than 90 calendar days to receive coverage.


Note: All calendar days are counted, and coverage must be available no later than the 91st day. For example, a plan may choose to permit coverage to be effective earlier than the 91st day for administrative convenience, but may not make the effective date on or after the 91st day.


Eligibility conditions:

Eligibility conditions based solely on the lapse of a time period can be no more than 90 days.


Other eligibility conditions under the terms of a group health plan (i.e., those that are not based solely on the lapse of a time period, such as being in an eligible job classification or achieving job related licensure requirements) are allowed unless designed to bypass the 90-day waiting period.


If eligibility conditions are based on employees (part-time or full-time) having completed a number of cumulative hours of service, the cumulative hours-of-service requirement cannot exceed 1,200 hours.


With respect to variable-hour employees whose benefit eligibility is based on a specific number of hours worked, the proposed regulations explain that "If a group health plan conditions eligibility on an employee regularly having a specified number of hours of service per period (or working full-time), and it cannot be determined that a newly hired employee is reasonably expected to regularly work that number of hours per period (or work full-time), the plan may take a reasonable period of time to determine whether the employee meets the plan's eligibility condition, which may include a measurement period of no more than 12 months that begins on any date between the employee's start date and the first day of the first calendar month following the employee's start date."


Generally, so long as coverage for a variable-hour employee who is determined to be a full-time employee is made effective within 13 months of an employee's start date, the eligibility criteria won't be viewed as a means of bypassing the 90-day waiting period.  

Review your benefits policy to ensure that your internal eligibility processes are not in violation of this new federal requirement.


Wellmark is here to inform, lead, assist and support you through all the ACA changes as you make your decisions about your group health plan. Talk to your Wellmark representative, broker, or agent about Wellmark coverage options that best meet the ongoing needs of you and your employees. Continue to monitor for updates.


Wellmark is not providing any legal advice with regard to compliance with the requirements of the Affordable Care Act (ACA) or the Mental Health Parity Addiction Equity Act (MHPAEA). Regulations and guidance on specific provisions of the ACA and MHPAEA have been and will continue to be provided by the U.S. Department of Health and Human Services (HHS) and/or other agencies. The information provided reflects Wellmark's understanding of the most current information and is subject to change without further notice. Please note that plan benefits, rates, renewal rate adjustments, and rating impact calculations are subject to change and may be revised during a plan's rating period based on guidance and regulations issued by HHS or other agencies. Wellmark makes no representation as to the impact of plan changes on a plan's grandfathered status or interpretation or implementation of any other provisions of ACA. Any questions about Wellmark's approach to the ACA of MHPAEA may be referred to your Wellmark account representative. Wellmark will not determine whether coverage is discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). Wellmark also will not provide any testing for compliance with Internal Revenue Code Section 105(h). Wellmark will not be held liable for any penalties or other losses resulting from any employer offering coverage in violation of section 105(h). Wellmark will not determine whether any change in an Employer Administered Funding Arrangement affects a health plan's grandfathered health plan status under ACA or otherwise complies with ACA.  Wellmark will not be held liable for any penalties or other losses resulting from any Employer Administered Funding Arrangement.  For purposes of this paragraph, an "Employer Administered Funding Arrangement" is an arrangement administered by an employer in which the employer contributes toward the member's share of benefit costs (such as the member's deductible, coinsurance, or copayments) in the absence of which the member would be financially responsible.  An Employer Administered Funding Arrangement does not include the employer's contribution to health insurance premiums or rates.

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