Short Answer: You cannot be denied health insurance because you have a pre-existing condition but, if you have been uninsured for more than 31 days, you can be denied coverage of the medical costs for your pre-existing condition(s) for up to 12 months after you enroll in an Individual Health Coverage plan in New Jersey.
What IS a pre-existing condition for health insurance coverage?
A pre-existing condition for an Individual Health Coverage plan in New Jersey is:
- A physical or mental condition within six months before enrollment (called a look-back period) for which a person received medical advice, recommendation, diagnosis, or treatment; or
- A physical or mental condition for which an “ordinarily prudent or careful” person would have sought medical care.
Some important details:
You may purchase Individual Health Coverage in New Jersey to cover you and/or your family members if you are not eligible to enroll in a group health plan, such as an employer or union plan, or you are not eligible for Medicare. The insurance carrier cannot refuse to enroll you in the plan and must provide coverage for all injuries or conditions that the plan includes except for pre-existing conditions. (Exceptions are explained below.)
There is NO pre-existing condition waiting or penalty period for persons enrolled in a group health plan (six or more employees) or a government-sponsored health plan in New Jersey. Group health plans are usually employer, church, or union group plans. Examples of government health plans include Medicaid, NJ FamilyCare, and Medicare.
Exceptions for pre-existing condition restrictions in an Individual Health Coverage plan in New Jersey:
- There is no 12-month waiting period when a person’s pre-existing conditions were diagnosed, treated, and covered under creditable coverage (prior comprehensive health insurance coverage) that ended less than 31 days before enrolling in the new Individual Health Coverage plan.
- When a pre-existing condition waiting period was not satisfied under the prior insurance plan and no more than 31 days have gone by without insurance, the new Individual Health Coverage plan’s waiting period will be only the balance of the waiting period. (For example, you canceled coverage in an Individual Health Coverage plan with a 12-month pre-existing waiting period after only six months. You enrolled in a new Individual Health Coverage plan within 31 days, so you will have a six-month waiting period in your new Individual Health Coverage plan before expenses for your pre-existing condition will be covered.)
- Persons who are HIPAA Eligible Individuals (under the federal Health Insurance Portability and Accountability Act of 1996) cannot be subject to a waiting or penalty period for coverage of pre-existing conditions.
HIPAA Eligible Individuals are persons who
- Have been covered by a group plan for at least 18 months without a gap in coverage for 63 days (and who did not lose their group coverage due to fraud or non-payment of premiums);
- Are not eligible for COBRA or other continuation health insurance coverage; and
- Are not eligible for a group or government plan, such as Medicaid or Medicare.
- Although a pregnancy that began before enrollment in an Individual Health Coverage plan is considered a pre-existing condition, some complications of pregnancy are not included in the pre-existing waiting or penalty period.
For more information about non-coverage of pre-existing conditions by New Jersey insurance carriers, please contact the New Jersey Department of Banking and Insurance at 1-609-633-1882 or see their Web site.
If your income is low and you think that you have been wrongly denied coverage of your health care needs, you may also contact your nearest Legal Services office or call LSNJ-LAW™, Legal Services of New Jersey’s statewide, toll-free legal hotline, at 1-888-LSNJ-LAW (1-888-576-5529) to see if you are eligible for free legal assistance. Hotline hours are Monday through Friday, 8:00 a.m. to 5:30 p.m. If you are not eligible for assistance from Legal Services, the hotline will refer you to other possible resources.
This information last reviewed 10/26/11