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 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 WeKnowReform.com for updates.
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