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Pre-Existing Conditions (PEC)


A condition occurring or present in the six month period prior to the enrollment date for a newly covered member, age 19 and older, for which medical advice, diagnosis, care or treatment (treatment shall include prescription or over-the-counter medication) was either received from or recommended by a physician.

(Note: The existing HIPAA restrictions on preexisting condition exclusions will continue to apply to allĀ enrollees (i.e., those age 19 and older) until plan/policy years beginning on or after January 1, 2014, when the expanded definition of a preexisting condition will apply to everyone.)

For individuals under age 19, pre-existing conditions are not applicable. These newly covered members are guaranteed issue.

(Note: This is effective for plan/policy years beginning on or after September 23, 2010. Please note: For plans in effect prior to March 23, 2010, preexisting waiting periods will continue to apply to individuals under age 19.)

PEC Conditions apply to our Individual and Small Employer products, some Self Funded Groups, HIPUTAH, and transition plans.

Pre-existing conditions are not covered while a member is in a Pre-Existing Wait period.

PEC Automatic Exclusions

There are some diagnoses and procedures that are automatically excluded from coverage while a member is in a Pre-Existing Wait period. These include:

Diagnoses:

Amenorrhea

Cataracts

Congenital Deformities

Cystocele

Dysmenorrhea

Enterocele

Infertility

Rectocele

Sleep Problems/Disorders

Urethrocele

Uterine Prolapse

Varicose Veins

Procedures:

Allergy testing and treatment

Bunionectomy

Carpal Tunnel surgery

Hysterectomy (except in cases of malignancy)

Joint replacement

Mammoplasty, reduction

Morton's Neuroma, surgical treatment

Myringotomy/Tympanotomy (with or without tubes insertion)

Nasal Septal repair, except injuries after effective date of coverage

Retained hardware removal

Sleep studies

Sterilization (except for tubal ligation performed at time of delivery)

Tonsillectomy/adenoidectomy

Pre-Existing Wait Period

New members to a health insurance plan may be placed in a Pre-Existing Wait Period

A standard wait period is 12 months.

Some plans require up to 18 months in the Wait Period if a member does not elect coverage during the first available enrollment period. They are then considered a late enrollee.

All or part of the Wait Period may be waived with proof of prior insurance depending upon the time that has elapsed between the end of the old policy and the date the new policy starts. This time is referred to as the "coverage gap."

The coverage gap must be 63 days or less between insurance carriers, including between the current and prior plan.

The prior plan is reviewed to determine the length of continuous coverage. Wait Periods may be pro-rated based on the coverage length of the prior plan if there has been less than 12 months of continuous coverage or 18 months for late enrollees.

During this Wait period, claims may require medical notes to be reviewed to determine if there is a Pre-Existing Condition (PEC).

Creditable Coverage Certificate (CCC)

Insurance Carriers provide certificates to their members as proof of prior insurance coverage whenever a plan is terminated.

With this proof, members may have all or part of the PEC wait period removed if there is no more than a 63 day gap between insurance carriers.

Attempts are made by SelectHealth to obtain CCC information

PEC letters are sent at the time of enrollment to advise members of their PEC status

The letter has the PEC Wait Period dates listed.

The letter requests and explains the purpose certificate of creditable coverage

How Does SelectHealth Help?

PEC information is included in new enrollment packets and on the web site for members to reference.

Insurance Brokers are educated so they can better explain PEC and the steps required to waive it to new members.

Prior and/or other coverage information is requested on the new enrollment application.

If prior coverage information is indicated on the application, but incomplete, a message is sent on every Explanation of Benefits (EOB) to the member explaining that the certificate of creditable coverage is still required.

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