GENERAL DESCRIPTION

Information Regarding Individual Plans: Pre-Existing Conditions, Credible Coverage, Portability and the Washington State Standard Health Questionnaire

Important: The following definitions and examples are only general in nature and should not be construed to be any part of an insurance policy certificate. Only the policy certificate determines coverage benefits, limitations and exclusions.

Credible Coverage – This is Important

Most group plans meet the definition of credible coverage. As of 7/1/2011, only the following four individual plans qualify as credible coverage: Lifewise Prime $1500, Regence Evolve Plus $1000, Group Health Coop Welcome $750 and the Group Health Options Balance $1750. All other individual plans are considered catastrophic coverage.

If you are changing from a credible coverage plan to a catastrophic plan you will receive credit for pre-existing condition waiting periods (the credit is based on the number of months coverage was in force and credited month for month). This is called portability. The one exception to the month for month credit is if you are applying for coverage with Regence. If you are coming off of a non-Regence group plan, Regence will only give you credit for pre-existing conditions if coverage was in force for at least 18 months. If you are transferring from an individual plan then the month for month credit applies if prior coverage was determined to be credible.

Once you move to a catastrophic plan your coverage will no longer be portable. This means that if you move from catastrophic coverage to a new group plan, a credible individual plan, or even another catastrophic plan, you will have to meet the pre-existing condition waiting period of the new plan. This is usually waived if you are staying with the same carrier but changing to a plan with less benefits (higher deductible). At the bottom of this page is the legal definition of a catastrophic plan.

Note regarding prior coverage credit: The old carrier must provide a certificate of creditable coverage within 30 days of termination of policy and at no charge to you. If your coverage starts before the new carrier has a copy of your proof of coverage, pre-existing conditions will apply. However, generally once the new carrier receives the proof of coverage certificate from you they will waive or credit the pre-existing condition waiting period retroactively to your new coverage start date.

Pre-Existing Conditions

A pre-existing condition is any medical condition, illness or injury that existed at any time prior to the Effective Date of coverage for which medical advice was given, for which a health care provider recommended or provided treatment, or for which a prudent layperson would have sought advice or treatment, within the six (6) months prior to the effective date.

Generally, no benefits are available for services or supplies furnished for any pre-existing condition (even if the condition worsens) during the first nine (9) months of coverage. This is called the pre-existing conditions waiting period.

Individual plans have a nine-month waiting period for pre-existing conditions. No benefits are provided for any medical condition for which treatment was received (or recommended), or for which a prudent person would have sought advice or treatment within the six months prior to the effective date of the plan. The waiting period does not apply to: individuals under age 19 and prenatal care (if the plan provides benefits for this).

EXCEPTION: In many cases the period of time an enrollee was covered under their old policy will be credited toward their new plan's pre-existing condition waiting period. In all cases, deductibles and benefit maximums will start over (deductibles and maximums will also reset on January 1^st regardless of enrollment date). Time continuously covered under the previous individual policy will not be credited on the new policy if:

The break in coverage was greater than 63 days
The previous policy was determined to not meet the definition of “credible coverage”

Organ Transplants Exception: Most carriers impose a 12-month waiting period for organ transplants with no credit for prior coverage. There may be exceptions to this limitation. Refer to carrier’s policy certificate for details.

The insurance carrier will determine whether a condition is a pre-existing condition subject to the waiting period on a case by case basis, taking into account the facts of the case.

Washington State Standard Health Questionnaire

This health questionnaire was created by the Washington State Health Insurance Pool (WSHIP). It is for people who apply for private, individual medical coverage with insurance carriers.

By completing this form, you will be giving your medical information to the insurance carrier. Your answers will determine if the insurance carrier will accept your application or if you will be referred to the Washington State Health Insurance Pool (WSHIP).

The insurance carrier will score your answers using a standard scoring system designed by WSHIP. The insurance carriers do not have control over the questions or the scoring system. If you are rejected for coverage and request an appeal, a carrier may then request further information. You may choose to supply this added information if you believe it will assist the carrier in scoring your questionnaire correctly.

The State Standard Health Questionnaire and information about the scoring system is available online. Currently applicants are allowed 299 points before being disqualified. The program was originally designed to allow approximately 92% of applicants to qualify. Applicants who are declined for coverage for health reasons can qualify for the Washington State Health Insurance Pool. Benefits and premium information are available online.

In most cases, you do not need to fill out a health questionnaire if you are:

Leaving group coverage due to termination of employment (regardless of size of group). Assumes 24 months of continuous coverage.
Applying for coverage after terminating COBRA continuation coverage (you do not have to exhaust COBRA to qualify under this provision). Assumes 24 months of continuous coverage.
Leaving Washington State Basic Health Plan. Assumes 24 months of continuous coverage.
With some carriers, if applying for coverage for a newborn child or newly adopted child of an existing individual enrollee withi 60 days.
Applying for coverage due to loss of group coverage and your employer is not required to offer you COBRA. You must have had at least 24 months of continuous group coverage and you are enrolling within 90 days of the qualifying event.
Applying for coverage due to relocating within Washington state to an area where your prior health plan isn't offered.
Applying for coverage because your health care provider (whom you have seen in the past 12 months) has cancelled from his or her prior insurance, and is contracting with a new carrier you are applying for.

You must apply for coverage within 90 days of relocation, provider cancellation or exhaustion of COBRA in order to have the Standard Health Questionnaire requirement waived.

Important Note

It is always important to confirm the pre-existing condition rules, credible coverage determinations, and Standard Health Questionnaire procedures before applying for coverage and especially before terminating your prior coverage. Never terminate prior coverage before your new coverage has been approved.

Definition of Catastrophic (Revised Code of Washington):

(5) "Catastrophic health plan" means:

     (a) In the case of a contract, agreement, or policy covering a single enrollee, a health benefit plan requiring a calendar year deductible of, at a minimum, $1,840.00 and an annual out-of-pocket expense required to be paid under the plan (other than for premiums) for covered benefits of at least three thousand five hundred dollars, both amounts to be adjusted annually by the insurance commissioner; and

     (b) In the case of a contract, agreement, or policy covering more than one enrollee, a health benefit plan requiring a calendar year deductible of, at a minimum, three thousand five hundred dollars and an annual out-of-pocket expense required to be paid under the plan (other than for premiums) for covered benefits of at least six thousand dollars, both amounts to be adjusted annually by the insurance commissioner; or

     (c) Any health benefit plan that provides benefits for hospital inpatient and outpatient services, professional and prescription drugs provided in conjunction with such hospital inpatient and outpatient services, and excludes or substantially limits outpatient physician services and those services usually provided in an office setting.

     In July 2008, and in each July thereafter, the insurance commissioner shall adjust the minimum deductible and out-of-pocket expense required for a plan to qualify as a catastrophic plan to reflect the percentage change in the consumer price index for medical care for a preceding twelve months, as determined by the United States department of labor. The adjusted amount shall apply on the following January 1st.