What is a Certificate of Creditable Coverage form and how does it affect coverage for pre-existing conditions?

The Health Insurance Portability and Accountability Act of 1996 placed limits on the extent to which your group coverage can exclude or limit coverage for pre-existing conditions. It excludes coverage for the treatment of conditions which existed within 6 months prior to your enrollment date. This exclusion complies with state and federal laws and will not exceed a period of 12 months from your enrollment date or 18 months from your enrollment date if you are a late enrollee. Pre-existing conditions do not include pregnancy, pre- or post-natal care or any complications with pregnancy. Pre-existing also does not apply to participants or dependents under age 19. Refer to your certificate for more detailed information regarding the pre-existing condition limitation.

For example, if you were covered by “creditable” health insurance for 12 straight months, with no lapse in coverage of 63 days or more, prior to your enrollment date with BPA (not a late enrollment), the pre-existing conditions exclusion of your coverage will not apply to you.

If you had less than 12 months of prior creditable coverage, the waiting period for coverage of a pre-existing condition will be shortened by the number of days you were covered under the prior qualifying health plan. For example, if you had:

•  High blood pressure as a pre-existing condition and
•  Three months of prior creditable health coverage and
•  Your new coverage with BPA excluded benefits for pre-existing conditions for 12-months, the 12 month waiting period would be reduced to 9 months, due to your three months of prior qualifying health coverage.

Most prior health coverage qualifies for this credit. It includes prior coverage under any of the following:

•  A group health plan
•  A non-group or individual health insurance
•  Part A or B of Medicare
•  Medicaid
•  The Active Military Health Program or CHAMPUS
•  A medical program of the Indian Health Service, or of a tribal organization
•  A State sponsored health benefits risk sharing pool
•  The Federal Employee Health Plan
•  A public health plan as defined by government regulations
•  The Peace Corps Health Program.

If you had prior creditable coverage but had a claim rejected by BPA due to a pre-existing conditions limitation or investigation, we may not have a record of your prior coverage. In order to receive credit for the time you were covered, you need to request a “Certificate of Creditable Coverage” form from your prior benefits carrier. Your prior carrier is required to give you this information if you ask for it. After receiving this form, you should attach a copy of it to the claim determination or letter you received from BPA and then return it to us by fax or mail.

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