6.  Dr Kristin Kahle’s Monday Report – Navigate HCR



Welcome back to our series on the ACA Toolkit. Today’s topic is excessive waiting periods.
A group health plan or issuer may not impose a waiting period that exceeds 90 days. A waiting period is the period of time that must pass before coverage for an employee or dependent who is otherwise eligible to enroll becomes effective.


Eligibility conditions that are based solely on the lapse of time are permissible for no more than 90 days. However, other conditions for eligibility are permissible, as long as they are not designed to avoid compliance with the 90-day waiting period limit. Permissible eligibility conditions include:


§  Being in an eligible job classification;

§  Achieving job-related licensure requirements specified in the plan’s terms; or

§  Satisfying a reasonable and bona fide employment-based orientation period.


A special rule applies if a group health plan conditions eligibility on an employee regularly working a specified number of hours per pay period (or working full time), and it cannot be determined that a newly hired employee is reasonably expected to regularly work that number of hours per period (or work full time).


In this type of situation, the plan may take a reasonable period of time to determine whether the employee meets the plan’s eligibility condition. This may include a measurement period that is consistent with the employer shared responsibility provisions (even if the employer is not a large employer). The time period for determining whether a variable hour employee meets the plan’s eligibility condition will comply with the 90-day waiting period limit if coverage is effective no later than 13 months from the employee’s start date, except where a waiting period that exceeds 90 days is imposed after the measurement period. If an employee’s start date is not the first of the month, the time period can also include the time remaining until the first day of the next calendar month.


Action Items:


¨  Review whether your plans impose a waiting period for participation.

¨  If a waiting period is imposed, ensure that it does not exceed 90 days.

¨  If it is unclear that a new employee will work the required number of hours, set a measurement period to determine whether the hours requirement will be met in the future.



Provided by:

Dr. Kristin L. Kahle “Dr. ACA”


Dr. Kahle is the CEO and Founder of NavigateHCR, a nationally recognized leader in Health Care Reform, a national speaker and educator, a benefit strategist and broker with over 20 years of experience in the industry and was awarded 2014 & 2015 Most Influential Women in Benefit Advising.