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What Are the Pre-existing Exclusion Periods in California for Individual Health Plans?

Maryalene LaPonsie | October 26, 2010

Question: I live in California and need to purchase health insurance because my COBRA benefits are expiring. I have a pre-existing condition and am worried about finding coverage for my illness. How long can a health insurance company exclude coverage for my disease?

Answer: California residents who have previously held group insurance, or continuation coverage such as COBRA, are protected by federal law from pre-existing condition exclusions.

The Health Insurance Portability and Accountability Act (HIPAA) guarantees certain individuals the right to buy individual medical coverage without any pre-existing condition exclusions. This guaranteed coverage applies if all the following criteria are met:
  • You have at least 18 months of medical insurance without a significant break (more than 62 days) in coverage
  • Your last medical coverage came from a group insurance plan
  • You lost your group coverage for a reason other than fraud or non-payment of premiums
  • You are not eligible for COBRA coverage or you have exhausted your COBRA benefits
  • You are not eligible for Medicaid, Medicare, or any other group health insurance plan

Because COBRA is a group plan, if you meet the other criteria, you should be able to purchase individual medical insurance without any pre-existing condition exclusions. If you are not eligible or you wait more than 62 days to begin your individual plan, the following pre-existing condition exclusions may apply under California law:
  • 12 months for plans covering one or two people
  • 6 months for family plans covering three or more people

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