What are pre-existing conditions and how do they impact coverage?
A Pre-existing condition is a health condition (other than a pregnancy) or medical problem that was diagnosed or treated during a specified timeframe prior to enrollment in a new health plan. Some pre-existing conditions may be excluded from coverage during a specified timeframe after the effective date of coverage in a new health plan. Plan documents will provide specific information on pre-existing conditions. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was signed into law on August 21, 1996. This law includes important new protections for millions of working Americans and their families who have pre-existing medical conditions or who might suffer discrimination in health coverage based on a factor that relates to the individual’s health.
Pre-existing conditions are a physical and/or mental condition of an insured person that existed prior to the issuance of their insurance policy, or that existed prior to issuance and for which treatment was received. Preexisting conditions will apply if an insured person: • Becomes insured under the policy and was not covered under Creditable Coverage; or • Becomes insured under the policy and was covered under Creditable Coverage for an aggregate period of fewer than 12 months. Generally, if a preexisting condition limitation applies, benefits for that condition will be limited to a small maximum dollar amount for the first 12 months of coverage, such as $500 or $1,000. Preexisting conditions will not apply if an insured person was covered under Creditable Coverage for an aggregate period of 12 months or more prior to the takeover date. If an insured person becomes insured under the policy and was covered under Creditable Coverage for an aggregate period of fewer than 12 months, we w
A pre-existing condition is a condition for which medical advice, diagnosis, care or treatment was recommended or received within the previous 6 months preceding the effective date of the coverage of an individual member. For members covered by a Traditional (Indemnity) Plan or by BlueChoice PPO, benefits for services shall not be available for any illness, injury or other pre-existing condition (except for maternity services, for which the pre-existing condition limitation is not applicable) until a member has had creditable coverage for 12 consecutive months. For members covered by BlueChoice Healthcare Plan (HMO), there are no pre-existing condition limitations. All in-network, covered services are eligible for benefits from the member’s first day of coverage. For members covered by BlueChoice Option (POS), there is no pre-existing condition limitation for in-network services. For out-of-network services, benefits are not available during a pre-existing limitation period. The pre-ex
A33. Pre-existing condition means an illness, injury or condition which existed during the six-month period immediately prior to either (a) the member’s effective date or (b) the first day of any waiting period required by the group, whichever is earlier. A condition is considered to have existed when the member: (1) sought or received medical advice for that condition; (2) received medical care or treatment for that condition; or (3) received medical supplies, drugs or medicines for that condition. No payment will be made for services or supplies for the treatment of a pre-existing condition during a period of six months following either the member’s effective date or the first day of any waiting period required by the group, whichever is earlier. However, this limitation does not apply to a child born to or newly adopted by an enrolled subscriber or spouse, or to conditions of pregnancy. Also, if the member was covered under creditable coverage, the time spent under the creditable co
Pre-existing means a condition, regardless of its cause, for which medical advice, diagnosis, care or treatment was received or recommended during a 6-month period immediately preceding the earlier of (a) the effective date of coverage or (b) the first day of the waiting period. Pregnancy is not a preexisting condition for the purposes of a Small Group plan and genetic information is not a preexisting condition for the purposes of a Small Group plan unless there has been a diagnosis of the condition related to the information. Effective date of coverage is the first day on which coverage under the Certificate begins. Expenses due to a pre-existing condition are covered only if the expense is incurred after 12 consecutive months beginning on the earlier of (a) the effective date of coverage or (b) the first day of the waiting period. Any time limits of the pre-existing condition exclusion will be reduced by the number of days a covered person was covered under a “Qualifying Prior Covera
