Patient Protection and Affordable Care Act’s 90 Day Waiting Regulation

By Scott Glovsky on March 13th, 2014 in Insurance, Wrongful Termination/Employment Law

On February 24, 2014, the U.S. Departments of Labor, Treasury, and Health and Human Services released final regulations for the Patient Protection and Affordable Care Act’s (known as “Obamacare”) restriction on the period of time a group health plan may wait before providing coverage to a person who is eligible for coverage through their employer and the person’s dependents.  The regulations mandate that the waiting time cannot exceed 90 days.  When calculating this waiting period, the regulations specify that all calendar days count in adding up the 90 day period and the first day of counting is the day of enrollment. While 90 days is the maximum “waiting period” in such circumstances, there is no law that would restrict a health care plan from offering a waiting period that is shorter than 90 days.

Further, this restriction only concerns employees who are otherwise eligible for coverage and does not require that plans cover employees such as part time workers.  Additionally, this restriction applies whether an employee is a new employee or simply a rehire.  This final regulation is very similar to the proposed regulations that the above-mentioned departments issued on March 21, 2013, but also includes some additions, clarifications, and exceptions.

For example, this regulation clarifies that any period before a late or special enrollment is not a waiting period and does not count towards the 90 day maximum.  The regulations provide that group health plan providers are able to avoid this 90 day waiting time restriction by instead requiring an employee to complete a particular number of hours of work before they become eligible for coverage but only if the service hour requirement is not more than 1,200 hours.

The regulations provide for a second exception to the waiting period restriction–eligibility conditioned on employees performing a certain amount of work hours for coverage.  In such circumstances, if a managed health care plan cannot determine whether a new employee is reasonably expected to work the specified hours, then the provider can wait up to 12 months before providing coverage so that it can determine whether the employee is truly eligible.  This being said, once the provider deems the employee eligible, it cannot impose a waiting period that exceeds 90 days after the 12-month investigation period.

This final regulation will apply only to group health plans and group health insurers for plan years beginning on or after January 1, 2015.

To see a full copy of the final regulations, you can go to:

http://www.gpo.gov/fdsys/pkg/FR-2014-02-24/pdf/2014-03809.pdf

Please see further Obamacare information at:   www.scottglovsky.com