Creditable Coverage FAQ
Personal Choice® PPO
What is a pre-existing condition exclusion?
Do non-group plans have pre-existing condition exclusions?
Are there any instances when the pre-existing condition exclusion in a health plan does not apply or can be reduced?
What if a member is transferring from a group plan other than a Blue Cross® and Blue Shield® Plan, or an affiliate of Independence Blue Cross?
Other than the two traditional, non-group plans identified above, are there any other non-group plans available that will allow an individual who does not qualify for a Blue to Blue transfer to avoid or reduce the pre-existing condition exclusion waiting period?
What is a pre-existing condition exclusion?
A pre-existing condition exclusion excludes coverage for a certain period of time for charges related to any medical condition or illness for which medical advice or treatment was recommended or received within a stated “look-back” period that precedes the effective date of coverage.
The usual pre-existing condition exclusion period excludes coverage for a one-year period after the effective date of coverage. The usual “look-back” period for identifying pre-existing conditions is usually one or five years before the effective date of coverage depending on the contract.
Review the contract or member materials for your health plan to determine whether your health plan has a pre-existing condition exclusion period and to identify the related pre-existing condition “look-back” period.
Do non-group plans have pre-existing condition exclusions?
Yes.
Are there any instances when the pre-existing condition exclusion in a health plan does not apply or can be reduced?
Yes. The pre-existing condition exclusion period in a health plan will be reduced for each month that a member qualifies for a “Blue to Blue” transfer.
A “Blue to Blue” transfer occurs when a member has previously been enrolled in a Blue Cross and Blue Shield Plan, or with an affiliate of Independence Blue Cross (IBC), for at least one month and then transfers directly without a break in coverage into a health plan offered by IBC. Members receive credit towards their pre-existing waiting period for up to 12 months from the time they were enrolled in the other Blue Plan.
What if a member is transferring into an individual plan from a group plan other than a Blue Cross and Blue Shield Plan, or an affiliate of Independence Blue Cross?
Individuals may continue coverage without being subject to a pre-existing condition exclusion only by enrolling in one of two traditional — sometimes called indemnity — individual plans that are offered by Independence Blue Cross and Highmark Blue Shield. These two traditional, individual plans can provide continued coverage without a pre-existing condition because they allow members to satisfy the eligibility requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
You are eligible to enroll in one of these two plans only if you satisfy all of the following eligibility requirements:
- You were enrolled in a health plan for the past 18 months.
- Your most recent coverage is group coverage, which can be a governmental plan or church plan. COBRA coverage is considered group coverage.
- You have exhausted COBRA benefits (if COBRA was available to you).
- Apply for one of these plans within 63 days of the last day of your group coverage.
- You no longer qualify for any other group coverage (including coverage under a spouse’s policy), Medicare or Medicaid.
- You may not be enrolled in an individual plan or any other health insurance coverage.
- Your most recent coverage was not terminated because of nonpayment of premiums or fraud.
- Provide evidence of coverage with a previous insurer through documentation (e.g., submitting a “Certificate of Continuous Coverage” from your previous employer; completing forms supplied by IBC) or through other means. These means include having your previous insurer call IBC or having IBC call your former employer or prior insurer to verify coverage.
- Please note that unlike most insurance plans where a dependent can be covered only if a parent is covered, a dependent can be covered in these plans even if the parent does not enroll in this coverage.
Additional information regarding the traditional plan designs for individuals who meet the HIPAA eligibility requirements can be obtained by calling Customer Service.
Other than the two traditional, non-group plans identified above, are there any other non-group plans available that will allow an individual who does not qualify for a Blue to Blue transfer to avoid or reduce the pre-existing condition exclusion waiting period?
The only other plans that will allow a member enrollment without being subject to pre-existing conditions are adultBasic and CHIP (The Children’s Health Insurance Program). CHIP and adultBasic are programs designed to meet the needs of low-income adults and their children.
To be eligible for these programs, an individual must satisfy income guidelines. Otherwise any individual who does not qualify for Blue to Blue transfer and enrolls in a non-group plan (e.g. Personal Choice) will have to satisfy the full waiting period for pre-existing conditions.
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