The 90-day rule

A group health plan or issuer generally may not impose a waiting period longer than 90 days after an employee or dependent is otherwise eligible for coverage. All calendar days count, including weekends and holidays. Coverage may become effective earlier; the rule is a maximum, not a required waiting period.

Eligibility conditions come first

The rule does not require an employer to offer coverage to every employee or define a particular eligible class. Other substantive eligibility conditions may apply, provided they are not designed to evade the waiting-period limit. A reasonable, bona fide employment-based orientation period may be permitted within applicable rules.

Administration checkpoints

• Define eligible classes and hours rules consistently in the plan document and enrollment system.
• Record the date the person satisfies eligibility, not merely the hire date.
• Count calendar days correctly and test month-start conventions against the 90-day maximum.
• Apply rehire and status-change provisions exactly as written.
• Coordinate employee contributions with the correct coverage-effective date.
• Audit carrier eligibility files against HRIS and payroll deductions.

Eligibility is different from special enrollment

Ordinary eligibility determines who may participate under plan terms. HIPAA special enrollment can give an otherwise eligible employee or dependent a right to enroll outside open enrollment after certain coverage losses or life events.