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Preexisting Exclusion

All Individual medically underwritten plans are subject to a preexisting condition exclusion. This means that they exclude coverage for preexisting medical conditions for the first 12 months of coverage.

For the HMO plans, we will look at any services received 90 days prior to the effective date of coverage to determine if there are any preexisting conditions. For PPO plans, we will look at any services received 12 months prior to the effective date of coverage.

There are two ways in which applicants may be able to waive or reduce the waiting period for a preexisting condition – through a Blue-to-Blue transfer or creditable coverage.

Blue-to-Blue Transfer

For a Blue-to-Blue transfer, the applicant must have coverage through a Blue Cross® or Blue Shield® plan. The plan must have been in force for 12 months without a break in coverage prior to the current application. The applicant may receive credit for each month of prior coverage up to the entire exclusion period of 12 months.

Prior enrollment in another Blue plan does not guarantee acceptance into this medically underwritten program. All applications are subject to underwriting approval.

Creditable Coverage

Applicants may qualify for creditable coverage if they had coverage through another plan. This plan must have been in force for 18 months without a break in coverage of more than 63 days prior to the current application. The applicant may receive credit for the entire exclusion period of 12 months.

Prior creditable coverage does not guarantee acceptance into this medically underwritten program. All applications are subject to underwriting approval.

Plans that qualify as creditable coverage include:

  • group or individual health plans, including governmental plans
  • COBRA continuation coverage
  • state high-risk pools
  • Indian Health Service
  • public health plans (such as a plan offered by a state)
  • federal or state employee benefits
  • Medicare
  • Medicaid

Plans that do not count as creditable coverage include:

  • accident or accident-only
  • dental- or vision-only
  • disability or liability plans
  • auto or homeowners’ plans
  • hospital indemnity
  • Workers’ compensation
  • specified disease policies (e.g., cancer policies)

What is needed to be considered for a reduction or waiver of the preexisting condition exclusion period?

  • Applicant must complete all parts of Section G (Other insurance).
  • Applicant must also submit a Certificate of Creditable Coverage for each qualifying individual to be covered on the plan.