Waiting Periods

Pre-Existing Conditions Fully-Insured Groups
This act, guarantees, among other things, that workers covered under virtually any prior health insurance plan can carry forward and receive credit for time served under the previous carrier to the new company’s plan. The credit of such time will be used toward the satisfaction of any pre-existing conditions waiting period, which would otherwise be required under the new insurance program as long as the gap in coverage is not longer than 62 days. Gaps in coverage are not considered creditable coverage. (A company-imposed waiting period is not
considered a gap in coverage.)

• Note: A pre-existing conditions waiting period cannot be applied to pregnancies.
• Pre-existing condition waiting periods cannot be applied to newborns, adopted children or children placed for the purpose of adoption if added to the membership within 63 days of birth or adoption.
• If the employee enrolls at his or her first opportunity, the pre-existing conditions waiting period begins on the employee’s date of hire, not at date of eligibility.

Certificate of Creditable Coverage
BCBSKS and Premier Blue issues certificates reflecting time served in a health product as required. This fulfills your (as the employer) and our (as the insurer) obligations with respect to the issuance of the certifications.

If an employee terminates employment prior to completing a company imposed waiting period, the employer will be required to issue a Certificate of Creditable Coverage reflecting the time the employee (and dependants) served, and the number of days between the end of the company-imposed waiting period and the effective date of coverage (also known as the “constructive waiting period”).

If the employee provides a Certificate of Creditable Coverage from his or her previous coverage indicating no more than a 62-day gap in coverage:

• The pre-existing conditions waiting period must be reduced to the extent of time served under creditable coverage.

If no Certificate of Creditable Coverage is provided, the pre-existing conditions waiting period will be imposed.

• Pre-existing conditions waiting period for fully insured groups will not be more than 90 days for health conditions identified in the 90 days prior to the hire date.
• Employees will be notified if they have a pre-existing conditions waiting period.
  • This notification will be on the Identification Card Supplement.
  • It will indicate the length of the pre-existing conditions waiting period to be served, the information from which the length was based and an appeals procedure should the employees disagree with the waiting period assigned.

Model General Notice of Pre-existing Condition Exclusion
Beginning July 1, 2005, any group health plan imposing a pre-existing waiting period must provide a written general notice of pre-existing condition exclusion to participants under the plan. This general notice of pre-existing condition exclusion must be provided as part of any written application materials distributed to those employees applying for group coverage. The Model General Notice of Pre-existing Condition Exclusion can be customized to include the group’s specific waiting period information.

The law requires that the employer group health plans and the insurer be accountable for the issuance of certifications of creditable coverage must be reduced upon coverage cancellation so the new carrier will know how much credit to give toward a pre-existing conditions waiting period.

How Pre-Existing Conditions Are Determined
As claims are received for patients who are subject to a pre-existing conditions waiting period they are reviewed for verification.

The verification begins with mailing of questionnaires to both the covered employee and the provider(s) of health care, requesting they supply us with a record of any condition for which the patient asked for or received medical treatment in the 90-day period immediately preceding the employment date.

• After the questionnaires are mailed, we will “pend” the file and wait for the responses for 14 days. If both responses are not received within this 14 days, processing of the claim(s) will be suspended until the responses are received. Upon receipt of the needed information, we will reopen our review and make proper determination of claims denial or payment.

For additional information regarding claims for pre-existing health conditions call 1-800-432-0216 ext. 4013.