Question
Mississippi
My new husband was employed for 3-4 months (11/03 through 04/04) and terminated with the company.His last date of effective coverage was 04/30/04. We were married 06/26/04, and I added him and my stepchildren to my policy,BCBS, with an effective date of coverage 07/01/04.
During his employment and under his coverage, he was being treated for a back injury.His insurance (also BCBS) paid without issue. We schedulled an appointment with his physician for 08/04, and continued his treatment. In October I recieved a request for medical records, and we obtained them and supplied them to my insurance as requested. I recieved notice in December 2004 that the claims would be unpaid secondary to his condition being preexisting.
My question is this: he was covered by BCBS for 3-4 months with his previous job. I had him effectively covered on my insurance before 63 days had passed without insurance coverage. How do we stand as far as getting these claims paid, and if we are liable for the claims, how long will it be before the condition is no longer considered preexisting and he can resume treatment?
All help appreciated.
Answer
Since your husband did not have continuous coverage for 12 months, they can consider his condition pre-existing for the difference between 12 months and the length of time he did have coverage. The fact that you had him on your insurance within 63 days means that the 3-4 months he did has coverage remains creditable, but does not change the fact that he did not have enough time covered to be free from a pre-ex clause.
Yes, you are responsible for the bills incurred that your insurance will not pay.
Answer
Mississippi
Thanks for your response. Ok, so we are responsible for the bill. The medical issue my husband faces is a ruptured disc. It WILL require additional treatment in future. As long as I maintain him on my insurance, how long will it take before his condition will be covered again and not considered preexisting? Or will it? He will have been covered on my insurance for 1 year this coming July, and had prior creditable coverage for 3-4 months.
Again, your information appreciated.
Answer
As I said in the above post, this condition will cease to be pre-existing when he has been covered on your insurance for 12 months minus the length of coverage he had. I can't be more specific than that because you are not being specific. If he was covered at his employer for three months, the condition will cease to be considered pre-existing when he has been on your insurance for nine months. If he was covered at his employer for four months, he will be covered for this condition when he has been on your insurance for eight. Only bills incurred after the condition is no longer considered pre-ex will be paid. There will never be a time when he will be covered for the bills incurred while his condition was considered pre-ex.
Answer
Mississippi
My apologies for presenting myself as obtuse. I didn't mean to make you repeat yourself. I'm a Type A who always seeks exact clarification, and you spelled it out for me by defining the subtraction of creditable coverage in your last post. Thanks again.
Answer
Mississippi
Ok cbq**************. here are the exact details. Spouse had no prior insurance coverage. Became employed with N.G.S.S and had coverage beginning 12/01/03 and ending 04/30/04. He had an effective date of coverage on my insurance 07/01/04. That is a 62 day break in coverage, 1 day less than the allowed 63 day break in coverage for creditability, right? I just got off the phone with Human Resources at my place of employment. I was instructed because he was not covered for a full 12 months prior to the break that it was not creditable and his condition will be considered preexisting until 07/01/05. Shouldn't he recieve the 5 month credit, making the condition non-preexisting on 03/01/05? I'm just hearing one thing from them, and one thing from this forum, and don't want to get the shaft. I'm young but not dumb, and I apologize if I'm wasting your, or anyone elses, time. I'm trying my best to learn and handle this on my own with some instruction from those more experienced. Thanks.
Answer
I believe that your HR department is wrong.
However, unless your plan is self-funded, it's not your HR department that makes the decision. You want to talk to someone at the insurance carrier. There should be a Customer Service Department that you can talk to. Since they are the ones who will be paying the claims, it's them you have to convince (and as yet, there's no indication that you will have to convince them; they know the laws pretty well), not your HR.
Talk to the insurance carrier and let me know what they say.
Answer
Mississippi
Thank you, thank you, thank you!!!!!! I went to the link you posted previously and printed a copy of the information presented. I then called BCBS of MS as you suggested and asked when Charlie's condition would no longer be considered pre-existing. I was quoted 07/01/05. I asked if they had a copy of his certificate of creditable coverage, and after review was told "yes, there it is, he was covered for 5 months 12/01/03 - 04/30/04....and therefore yes, he should only be subject to a 7 month exclusion..which would make his condition coverable as of 02/01/05" !!!
Even though we are responsible for the pre-existing bill, I think it's knowledge well worth the price. Atleast now I have a working knowledge of Hippa and can be assured it will work for me again in the future. Maybe it's silly, but I feel like I've really accomplished something today, and you were a big help.
I'll be leaving you alone now
Answer
Congratulations! I'm glad it worked out for you, and glad I was able to help!