Waiting period or pre-existing exclusion

What it means

Your plan is saying one of two things. Either you used the care before a waiting period ended, for example after starting a new job or plan, or the plan excludes a condition you had before your coverage began. Both are tied to dates and to the exact words in the plan document.

This page cannot tell you what limits the law places on waiting periods or on pre-existing condition exclusions. The rules this site has verified do not cover them, so it does not state them. Whether your plan may apply the rule it used is a question for your plan document and your regulator, and the steps below show how to ask.

A denial because you are not eligible is still a denial you can appeal inside the plan. It is not covered by the federal external review process.

Who has to act first

You do. Start with the dates:

1. Find your coverage effective date on your enrollment confirmation, member card or the plan’s letter.
2. Compare it to the date of service on your explanation of benefits.
3. Ask your employer’s human resources office or the plan to confirm the date in writing. Enrollment errors and delayed entries happen, and a date mistake is the quickest fix.

For a job-based plan or a non-grandfathered individual plan, you have at least 180 days after you receive the denial notice to file the first appeal; your plan may allow more. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines. Check the date on your notice, which controls.

Arguments that work

• The dates. Show that your coverage began before the service, with your enrollment confirmation, payroll deductions or premium payments.
• The plan wording. The notice must name the specific plan provisions relied on. Ask for the provision and read it. Does it say what the plan says it says, and does it apply to this service?
• Ask which rule allows it. Ask the plan, and your employer if the plan is a job-based one, to state in writing which rule it relied on. Then ask your regulator.
• Other coverage. If you had earlier coverage that was still active on the service date, ask that plan to pay.
• Mistakes about your condition. If the plan says the condition pre-dated coverage, ask what record it relied on and ask for the claim file.

Evidence to gather

• Enrollment confirmation, member card and any plan letter with dates (you).
• Pay stubs showing premium deductions, or premium payment records (you or your employer).
• The plan document with the waiting period or exclusion wording (the plan, in writing).
• Your explanation of benefits showing the date of service (the plan).
• The plan’s claim file and the record it used on your condition (the plan).

What to send

Send your employer’s human resources office a request to confirm the date, then a written appeal with the proof of your coverage dates. Ask for the decision in writing. If the plan does not answer or you are stuck, a regulator can help. For a private employer plan the regulator is the Employee Benefits Security Administration (1-866-444-3272). For a policy sold by an insurance company, it is your state insurance department.

When this is not worth an appeal

If the dates are right, the plan document says the waiting period applies to this service, and your regulator confirms the rule is allowed, an appeal has little to argue. Look instead at payment plans, financial assistance, other coverage, and whether your doctor can safely schedule non-urgent care after your coverage starts.