HIPAA Title II
Health Insurance Portability & Accountability Act of 1996
The following information is provided to inform the member of certain provisions contained in the Group Health Plan and related procedures that may be utilized by the member in accordance with Federal law.
For detailed information, refer to the HIPAA notice.
Pre-existing Conditions Exclusion Provision
A pre-existing conditions exclusion period may apply to you, if a pre-existing conditions exclusion provision is included in the Group Health Plan that you are or become covered under. If your plan contains a pre-existing conditions exclusion, such exclusion may be waived for you if you have prior creditable coverage.
Creditable coverage includes coverage under a group health plan (including a governmental or church plan), health insurance coverage (either group or individual insurance), Medicare, Medicaid, military-sponsored health care (CHAMPUS), a program of the Indian Health Service, a State health benefit risk pool, the FEHBP, a public health plan as defined in the regulations, and any health benefit plan under section 5(C) of the Peace Corps Act. Not included as creditable coverage is any coverage that is exempt from the law (e.g., dental only coverage or dental coverage that is provided in a separate policy or even if in the same policy as medical, is separately elected and results in additional premium).
If you had prior creditable coverage within the 90 days immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be waived. The determination of the 90-day period will not include any waiting period that may be imposed by your employer before you are eligible for coverage.
If you had no prior creditable coverage within the 90 days prior to your enrollment date (either because you had no prior coverage or because there was more than a 90 day gap from the date your prior coverage terminated to your enrollment date), we will apply your plan’s pre-existing conditions exclusion (to a maximum period of 12 months).
If you have any questions regarding the determination of whether or not a pre-existing conditions exclusion applies to you, call the Member Services telephone number on your ID card.
Providing Proof of Creditable Coverage
Generally, you will have received Certification of Prior Group Health Plan Coverage from your prior medical plan as proof of your prior coverage. You should retain that Certification until you submit a medical claim. When a claim for treatment of a potential pre-existing condition is received, the claim office will request from you that Certification of Prior Group Health Plan Coverage, which will be used to determine if you have Creditable Coverage at that time.
You may request a Certification Of Prior Group Health Plan Coverage from your prior carrier(s) with whom you had coverage within the past two years. Our Service Center can assist you with this and can provide you with the type of information that you will need to request from your prior carrier.
The Service Center may also request information from you regarding any pre-existing condition for which you may have been treated in the past, and other information that will allow them to determine if you have creditable coverage.
Special Enrollment Periods
Due to Loss of Coverage
If you are eligible for coverage under your employer’s medical plan but do/did not enroll in that medical because you had other medical coverage, and you lose that other medical coverage, you will be allowed to enroll in the current medical plan during special enrollment periods after your initial eligibility period, if certain conditions are met. These Special Enrollment Rules apply to employees and/or dependents that are eligible, but not enrolled for coverage, under the terms of the plan.
An employee or dependent is eligible to enroll during a special enrollment period if each of the following conditions is met:
- When you declined enrollment for you or your dependent, you stated in writing that coverage under another group health plan or other health insurance was the reason for declining enrollment, if the employer required such written notice and you were given notice of the requirement and the consequences of not providing the statement; and
- When you decline enrollment for you or your dependent, you or your dependent had COBRA continuation coverage under another plan and that COBRA continuation coverage has since been exhausted (i.e., ceased for any reason),
-- OR --
If the other coverage that applied to you or your dependent when enrollment was declined was not under a COBRA continuation provision, either the other coverage has been terminated as a result of the loss of eligibility or employer contributions toward that coverage have been terminated. Loss of eligibility includes a loss of coverage as a result of legal separation, divorce, death, termination of employment, or reduction in hours of employment.
For Certain Dependent Beneficiaries
If your Group Health Plan offers dependent coverage, it is required to offer a dependent special enrollment period for persons becoming a dependent through marriage, birth, or adoption or placement for adoption. The dependent special enrollment period must last for not less than 31 days from the date of the marriage, birth, adoption or placement for adoption. The dependent may be enrolled during that time as a dependent of the individual. If the employee is eligible for enrollment, but not enrolled, the employee may also enroll at this time. In the case of the birth or adoption of a child, the spouse of the individual also may be enrolled as a dependent of the employee if the spouse is otherwise eligible for coverage but not already enrolled. I f an employee seeks to enroll a dependent during the special enrollment period, the coverage would become effective as of the date of birth, of adoption or placement for adoption, or marriage.
Special Enrollment Rules
To qualify for the special enrollment, individuals who meet the above requirements must request enrollment no later than 31 days after one of the events described above. The effective date of coverage for individuals who lost coverage will be the date coverage is elected. If you seek to enroll a dependent during the special enrollment period, coverage for your dependent (and for you, if also enrolling) will become effective as of the date that the qualifying event occurred, (for marriage, as of the enrollment date) once the completed request for enrollment is received.