Dealing with Preexisting Conditions Regarding Wisconsin Health Insurance

Preexisting Conditions

A group health benefit plan can impose a preexisting condition waiting period only if it defines a preexisting condition as a physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received in the six-month period prior to an individual's enrollment date under the group health benefit plan. Pregnancy cannot be considered a preexisting condition, nor can genetic information be treated as a preexisting condition without a diagnosis of a condition related to the information. Newborns, adopted children, and children placed for adoption under age 18 are not subject to a preexisting condition waiting period when enrolling in a group health benefit plan if the child was covered under other creditable coverage within 30 days of birth, adoption, or placement for adoption, and the child has not had a break in coverage longer than 62 days.

A group health benefit plan may not impose a preexisting condition waiting period longer than 12 months except when an individual is a "late enrollee." A "late enrollee" means an individual who enrolls under a group health benefit plan at any time other than when first eligible to enroll. Individuals who enroll during a special enrollment period, or after previously waiving coverage because they were covered under other health insurance coverage, are not considered "late enrollees." This is described more completely in the section titled, "Special Enrollment Periods."

Although Wisconsin insurance laws require that a "late enrollee" be offered coverage, an insurer may postpone coverage for no more than 18 months for a "late enrollee" who elects coverage, require the "late enrollee" to meet an 18-month preexisting condition waiting period, or apply a combination of the two restrictions, not to exceed 18 months. A preexisting condition waiting period may be reduced as described in the section titled, "What is Portability?"

Individual health plans may define a preexisting condition differently than group health benefit plans. Generally, individual health plans cannot impose a preexisting condition waiting period of more than two years from the date of policy issue, unless the policy specifically excludes the named condition from coverage by rider.