Pre-existing Conditions FAQ

What is a pre-existing condition?

A pre-existing condition means any medical condition for which medical advice, diagnosis, care or treatment was recommended or received within six (6) months prior to the Member's enrollment date.

Which plans still contain pre-existing condition exclusions now that the Affordable Care Act is being implemented?

If you or your employer purchased a new plan in 2014 or afterward, it does not contain a pre-existing condition exclusion. If your plan year started in 2013 or earlier, the plan has a pre-existing condition exclusion. If you renew that plan during 2014 or afterward under the transitional relief allowed by the Federal Government and the Oregon Insurance Division, the pre-existing condition exclusion will remain until you move to a plan that includes the changes mandated by the Affordable Care Act.

What conditions are not pre-existing conditions?

Pregnancy; genetic information in the absence of a diagnosis of the condition related to such information; and services provided to a newly born or adopted child are not administered as pre-existing conditions.

What documentation should new groups provide?

Producers submitting new groups submit six months of prior carrier billing with applications. Billing will be used to determine creditable coverage timeframes.

When does the six-month exclusion period begin?

The six-month exclusion period begins on the enrollment date of a Member. The enrollment date is the earlier of the Effective Date of Coverage or the first day of any required Eligibility Waiting Period (probationary period).

How are ongoing enrollments handled, and what are certificates of creditable coverage?

The exclusion period is reduced by creditable coverage when an insured individual changes from one health plan to another and presents a document showing prior health-care coverage, called "a certificate of creditable coverage."

Such individuals receive credit for previous coverage that occurred, without a break in coverage, of 63 days or more. Any coverage that ended more than 63 days prior a Member's enrollment date is not credited.

Creditable coverage includes any group health-care coverage (including the Federal Employees Health Benefits Plan and the Peace Corps), individual health care coverage, COBRA, Medicare, Medicaid, TRICARE, S-CHIP, Indian Health Service or tribal organization coverage, state high-risk pool coverage, or a domestic or foreign public health plan.

How does the pre-existing conditions policy apply to riders?

Pre-existing conditions will not apply to pharmacy benefits, alternative care or chiropractic benefits, or to routine vision benefits. Mental health and chemical dependency services are not endorsements, and so the pre-existing exclusion will apply to these conditions.