Florida Individual and Group Health
Insurance Pre-Existing Conditions Limitations
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Preexisting Condition Exclusion
Creditable Coverage Certificate of Coverage
Preexisting Condition Waiting Periods
Florida Summary
Preexisting condition waiting periods can be offset for one
person and 2-50 person groups if the group has 12 months of
creditable coverage with no more than a 63 (not 30) day lapse
between coverage. For both one person and 2-50 person groups, if
the group has less than 12 months of creditable coverage and no
more than a 63 day lapse between coverage, they will receive
credit for these months of coverage (6/12). At the end of the 12
months there will be no preexisting condition waiting period. If
there is no creditable coverage, a one person group is subject to
a 24 month look-back and a 24 month preexisting condition waiting
period. A 2-50 person group with no creditable coverage is
subject to a 6 month look-back and a 12 month preexisting
condition waiting period.
Maternity and Newborns Florida Summary
Pregnancy will not be considered a preexisting condition and
is covered regardless of prior coverage. The only exception is a
one person group with no prior creditable coverage who became
pregnant prior to the plan effective date. In this case, the
pregnancy will be treated as a preexisting condition and will not
be covered.
A one person group with less than 12 months of creditable coverage can receive credit for the months of coverage. After fulfilling preexisting condition waiting period, the pregnancy must be covered (if applicable).
Newborns who are not enrolled within 30 days of birth may be subject to a preexisting condition waiting period.
HIPAA Federal Guidelines for Pre-existing Conditions
What is a "preexisting condition exclusion" (also called a pre-ex) and how is it used?
| A "preexisting condition exclusion" is a limitation or exclusion of health benefits based on the fact that a physical or mental condition was present before the first day of coverage. However, HIPAA limits the extent to which a group health plan or issuer can apply a preexisting condition exclusion, and, as stated above, prohibits issuers of individual health insurance from applying a preexisting condition exclusion to an "eligible individual.". |
| A preexisting condition exclusion is limited to a physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 month period ending on the enrollment date in a plan or policy. |
| During the preexisting condition exclusion period, the group health plan or issuer may opt not to cover or pay for treatment of a medical condition based on the fact that the condition was present prior to your enrollment date under the new plan or policy. (The plan or issuer must, however, pay for any unrelated covered services or conditions that arise once coverage has begun.) The enrollment date is the first day of coverage, or if there is a waiting period before coverage takes effect, the first day of the waiting period. |
| A group health plan can apply a preexisting condition exclusion for no more than 12 months (18 months for a late enrollee) after your enrollment date and the preexisting condition exclusion period must be reduced by your prior creditable coverage. |
| A group health plan cannot apply a preexisting condition exclusion to an individual who had creditable coverage (without a break of 63 or more days) of 12 months (18 months for a late enrollee). |
What is creditable coverage?
| The purpose of creditable coverage is to give you credit for previous health coverage against the application of a preexisting condition exclusion period when moving from one group health plan to another, from a group health plan to an individual policy, or from an individual policy to a group health plan. |
| You will receive credit for your previous coverage that occurred without a break of 63 days or more. Any coverage occurring prior to a break in coverage of 63 days or more would not have to be credited against a preexisting condition exclusion period. (Some States' laws may provide greater protections.) For example, John Doe had coverage for two years followed by a break in coverage for 70 days, and then resumed coverage for eight months. He would receive credit against any preexisting condition exclusion only for eight months of coverage; no credit would have to be given for the two years of coverage prior to the break of 63 days or more. |
| Most health coverage is creditable coverage, including prior coverage under a group health plan (including a governmental or church plan), health insurance coverage (either group or individual), Medicare, Medicaid, a military-sponsored health care program such as CHAMPUS, a program of the Indian Health Service, a State high risk pool, the Federal Employees Health Benefit Program, a public health plan established or maintained by a State or local government, and a health benefit plan provided for Peace Corps members. |
How do I show that I have creditable coverage?
| In general, you should receive a certificate from your current plan or issuer when your coverage ceases, such as when you change jobs. This certificate contains information that will demonstrate creditable coverage. A model certificate is attached; however, plans and issuers are not required to use it. |
| If you do not receive a certificate and your new plan or issuer wants to apply a preexisting condition exclusion, ask your new plan or issuer to help you get a certificate from your old plan or issuer. |
| If you still cannot get a certificate, you can use a variety of evidence to prove creditable coverage. Acceptable documentation includes: pay stubs that reflect a premium deduction, explanation of benefit forms (EOBs), a benefit termination notice from Medicare or Medicaid, and verification by a doctor or your former health care benefits provider that you had prior health coverage. |
| You may request a certificate from your plan or issuer at any time, free of charge. So, for example, you can request a certificate ahead of time if you know you will be changing jobs. |
How do I get a certificate of creditable coverage?
| For employment-related coverage and individual health insurance, the plan or issuer offering health coverage must provide the certificate of creditable coverage without charge and generally within a reasonable time period. |
| In general, individuals have the right to receive a certificate automatically (an "automatic certificate") when they lose coverage, and when they begin or end COBRA, or upon request within 24 months after they lose coverage. |
| The certificate must be provided in writing. In certain circumstances, the certification information may be provided by telephone if that is acceptable to the new plan or issuer, you, and the source of prior coverage. For example, Jane Doe gets a new job a week after quitting her old job. Her previous health plan has not yet issued a certificate of creditable coverage and her new plan wonders if it's OK to call and verify her creditable coverage in order to speed up the paperwork. This is fine with Doe and the previous plan, which has the capability of providing the necessary information over the telephone. |
What period of time does a certificate cover?
| It depends on whether the certificate is issued automatically or upon request. |
| For a certificate that is issued automatically, the certificate may reflect only the most recent period of continuous coverage under a coverage option offered by a plan. |
| For a certificate that is issued upon request, it should reflect each period of continuous coverage under the plan, ending within the 24 months prior to the date of request. |
| For example, John Doe worked for the Multi-Large Corporation, which offers its employees a choice of three different plans: a health maintenance organization (HMO), a fee-for-service indemnity plan, and a preferred provider organization (PPO). During the open season, Doe switched from the HMO to the PPO. Six months later, he left the Multi-Large Corporation, and the issuer of the PPO provided a certificate for the six months during which it covered Doe. If Doe wants to demonstrate that he had 12 months of creditable coverage, he needs to ask the Multi-Large Corporation to give him a certificate for the entire time he was covered under its plan. (The plan should already have made arrangements that assured this result.) This certificate would reflect all periods of creditable coverage that ended within 24 months of Doe's request. |
When do plans or issuers need to start providing certificates of creditable coverage?
| Plans or issuers do not need to provide certificates before June 1, 1997. However, certain certification requirements apply to periods of coverage and events that occur after June 30, 1996. |
| By June 1, 1997, plans or issuers must arrange to have certificates delivered to ALL individuals who lost coverage, or who began or ended COBRA between October 1, 1996, and May 31, 1997. Plans or issuers do have an option of providing a notice (attached) instead of an actual complete certificate, provided that the plan or issuer furnishes a certificate on request. |
| After June 1, 1997, plans or issuers must arrange to provide certificates in a timely manner to individuals as they lose coverage, or begin or end COBRA. |
| By July 1, 1998, plans or issuers must also provide certificates with the names and individual dates of coverage of all dependents (until they may simply indicate that you had family or spousal coverage). |
What do I do once I receive a certificate?
| Make sure all the information is accurate. If you are in a group plan, your employer can tell you who you need to contact to make corrections. If you have an individual policy, contact the issuer. |
| You should keep your certificate in a safe place. You will need the certificate if you change health coverage and your new plan or issuer wants to apply a preexisting condition exclusion period to you. The certificate might also help you obtain coverage without a preexisting condition exclusion period if you buy health insurance other than through an employer group health plan. |
| If you need to demonstrate creditable coverage to reduce a preexisting condition exclusion period in your new plan, give the certificate to the plan administrator of your new plan or present it to the issuer if you are buying a policy in the individual market. |
| It is strongly recommended that you keep employment documentation and other insurance and benefit information in case you need them. |
What if I don't get a certificate? What if I lose it?
| If you do not receive a certificate before the time you should have received it, or before you need it, your first step should be to contact the plan administrator of your prior plan and request a copy, free of charge. If any part of your creditable coverage was through an issuer, you can also contact the issuer for a certificate that reflects that part of your creditable coverage. |
| If you lose your certificate, you can go back and request another one, free of charge. |
| If you do not receive a certificate, you can use a variety of evidence to prove creditable coverage. Acceptable documentation includes: pay stubs that reflect a premium deduction, explanation of benefit forms (EOBs), a benefit termination notice from Medicare or Medicaid, and verification by a doctor or your former health care benefits provider that you had prior health coverage. |
John K. Arnold
Florida Health Insurance
Group, Employee Benefits & Individual Health Insurance Specialist
Website Address www.floridahealthinsurance.com
E-Mail:
John K Arnold
Phone: 407-592-0311
Phone: 888-592-0311 X 703
Fax: 407-386-7053
Skype: john.k.arnold
Twitter: fl_health_insur
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