Pre-Existing Condition Clause

[somarco]

Jen, I have seen the DOL version before and, as indicated, it is squishy. My blogging partner and I tried to track down a definitive definition of creditable coverage years ago and never came up with a "credible" answer. We cover things like HIPAA, COBRA and the wonderful world of PCIP. Enjoy.

You may or may not find this trip down memory lane entertaining or enlightening.

InsureBlog: HIPAA and Maternity: A Dialectic (or a Debacle)…

InsureBlog: COBRA Crunch

InsureBlog: Dangerous Carrier Games

InsureBlog: PCIP Turnabout

 

[somarco]

From my FMO

I called New Era and the answer I received was that, for open enrollment, pre-x is waived on all plans with or without prior creditable coverage.

 

[smokin goose]

Is the VA credible coverage?

 

[ecotainer]

From the NAIC Model Regulation for Med Supp. States may have modifications in their regulations. Each state's definition of creditable coverage should appear somewhere in it's regs.

F. (1) "Creditable coverage" means, with respect to an individual, coverage of the individual provided
under any of the following:
(a) A group health plan;
(b) Health insurance coverage;
(c) Part A or Part B of Title XVIII of the Social Security Act (Medicare);
(d) Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under
section 1928;
(e) Chapter 55 of Title 10 United States Code (CHAMPUS);
(f) A medical care program of the Indian Health Service or of a tribal organization;
(g) A state health benefits risk pool;
(h) A health plan offered under chapter 89 of Title 5 United States Code (Federal Employees Health
Benefits Program);
(i) A public health plan as defined in federal regulation; and
(j) A health benefit plan under Section 5(e) of the Peace Corps Act (22 United States Code 2504(e)).

(2) "Creditable coverage" shall not include one or more, or any combination of, the following:
(a) Coverage only for accident or disability income insurance, or any combination thereof;
(b) Coverage issued as a supplement to liability insurance;
(c) Liability insurance, including general liability insurance and automobile liability insurance;
(d) Workers' compensation or similar insurance;
(e) Automobile medical payment insurance;
(f) Credit-only insurance;
(g) Coverage for on-site medical clinics; and
(h) Other similar insurance coverage, specified in federal regulations, under which benefits for medical
care are secondary or incidental to other insurance benefits.

(3) "Creditable coverage" shall not include the following benefits if they are provided under a separate
policy, certificate or contract of insurance or are otherwise not an integral part of the plan:
(a) Limited scope dental or vision benefits;
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(b) Benefits for long-term care, nursing home care, home health care, community-based care, or any
combination thereof; and
(c) Such other similar, limited benefits as are specified in federal regulations.

(4) "Creditable coverage" shall not include the following benefits if offered as independent, noncoordinated
benefits:
(a) Coverage only for a specified disease or illness; and
(b) Hospital indemnity or other fixed indemnity insurance.

(5) "Creditable coverage" shall not include the following if it is offered as a separate policy, certificate or
contract of insurance:
(a) Medicare supplemental health insurance as defined under section 1882(g)(1) of the Social Security
Act;
(b) Coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code;
and
(c) Similar supplemental coverage provided to coverage under a group health plan.

 

[somarco]

(a) A group health plan;
(b) Health insurance coverage;

Maybe I missed it, but where do they define group health and individual health?

 

[steveadlman]

Well you've got less than 3 weeks to get her written up. so you better get busy. UHC has a 3 month waiting period for pre existing conditions, so I wouldn't use them.

I wrote a client with UHC during his open enrollment period. He had already been diagnosed with cancer and started his radiation and chemo treatments the same month his policy went into effect. UHC paid all of his claims with no waiting period.

 

[germanwine1]

I wrote a client with UHC during his open enrollment period. He had already been diagnosed with cancer and started his radiation and chemo treatments the same month his policy went into effect. UHC paid all of his claims with no waiting period.

That's good to know. I have a prospect in the aame situation.

 

[WCMason]

I've always understood "creditable coverage" as general term that can mean any coverage you get credit for having as determined by the entity you're applying with.

So VA coverage is not creditable for Part B, but is creditable for Part D, for example.

Active employer coverage is creditable for Part B, but retiree coverage or COBRA is not. But COBRA and retiree coverages are creditable for Part D.

The one thing I think we can all agree on is that any agent who uses the term "credible" instead of "creditable" should be sent to a reeducation camp before being allowed to write another app.

 

[smokin goose]

I've always understood "creditable coverage" as general term that can mean any coverage you get credit for having as determined by the entity you're applying with. So VA coverage is not creditable for Part B, but is creditable for Part D, for example. Active employer coverage is creditable for Part B, but retiree coverage or COBRA is not. But COBRA and retiree coverages are creditable for Part D. The one thing I think we can all agree on is that any agent who uses the term "credible" instead of "creditable" should be sent to a reeducation camp before being allowed to write another app.

What about incredible? Would that work?

 

[yogooglethis]

I've always understood "creditable coverage" as general term that can mean any coverage you get credit for having as determined by the entity you're applying with.

So VA coverage is not creditable for Part B, but is creditable for Part D, for example.

Active employer coverage is creditable for Part B, but retiree coverage or COBRA is not. But COBRA and retiree coverages are creditable for Part D.

The one thing I think we can all agree on is that any agent who uses the term "credible" instead of "creditable" should be sent to a reeducation camp before being allowed to write another app.

yes I agree that it is increditable that that happens.