Waiting Period under PPACA

[Guest strayhorn]

Would it be permissible under PPACA to require that a participant have two years of participation in the plan before they are eligible for a particular benefit? Would it matter if the benefit is not an essential health benefit (e.g., weight loss surgery, TMJ surgery)? Thanks.

[leevena]

You cannot have a seperate waiting period for any eligible expense under the group plan. Sorry.

[Guest strayhorn]

I thought you could have a waiting period of up to 90 days. So, why can't you have a waiting period of one group that is say 30 days and another that is 60 days (assuming it is nondiscriminatory)? Also, is a period tied to "particpation" in the plan as opposed to service itself really a waiting period? It is not based "solely" on the passage of time. Thanks.

[leevena]

Sorry, but I must have misread your first question. I thought you asked if you could have a seperate waiting period for a particular expense that is covered under the health plan.

You can have a waiting period up to 90 days, and actually there can be some slightly more due to issues such as obtaining a certification/license for work. You can also have different waiting periods.

I don't understand the last part "Also, is a period tied to "particpation" in the plan as opposed to service itself really a waiting period? It is not based "solely" on the passage of time"

[Guest strayhorn]

I know that you could not require that an employee have more than 90 days of service in order to participate in a plan (other than the special rule for hourly employees up to 1200 hours). My question is whether you could make an employee wait more than 90 days for a benefit based on "participation in the plan" as opposed to service itself.

In other words, I know I can't say you will not be eligible until you have one year of service--clearly that's based only on the passage of time. Could I say though that you will not be eligible until you have one year of actual particpation in the plan itself? The provision is designed to cover people based on their plan participation--not their service. (I know it may be a stretch.)

Thanks.

[leevena]

That is an interesting question, and my guess is no. But again, I am assuming you mean waiting for an eligible expense. For example, if the group health plan covers weight loss surgery as an eligible expense, you cannot deny that coverage to someone.