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Pre-Existing Condition Exclusions

Should the ACA be repealed, these pre-existing exclusions could be reinstated on all plans. Currently, only medically underwritten plans like short term medical plans are subject to pre-existing condition exclusions

Pre-existing Conditions are those health conditions which were diagnosed or treated by a provider during the 12 months prior to the coverage effective date, or for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis or treatment. Any Pre-existing Condition will be subject to a waiting period of 365 days.

Effective July 1, 2012, the pre-existing waiting period on new Blue Cross and Blue Shield of Illinois (BCBSIL) individual policies can now be offset by prior individual coverage with another carrier, provided:

• Application is received on or after July 1, 2012
• The prior coverage was an individual policy (temporary or permanent)
• There was no more than a 63-day lapse in coverage between the cancellation date of the prior carrier’s individual or group policy and the signature date on the BCBSIL application for coverage
• A Certificate of Creditable Coverage is submitted with the BCBSIL application
• This INCLUDES maternity coverage. The maternity waiting period will be waived if you have had prior maternity coverage for at least 12 months

Creditable coverage does not include:

• Accident only or disability income insurance
• Liability insurance or coverage issued as a supplement to liability insurance
• Worker’s Compensation
• Credit-only insurance
• Coverage for onsite medical clinics
• Dental or vision benefits
• Long-term care, nursing home care, home health care or community based care coverage
• Coverage for a specified disease or illness
• Hospital indemnity

Exception for Prior Group Plan Coverage

There’s a consumer-friendly exception if you’ve been continuously insured under a group health plan (no more than a 63 day gap in coverage). The time insured under that group plan will offset the 12-month waiting period.

For example, if you were insured under an employer’s BCBSIL or Humana group health plan for a year or more, and you immediately enroll in a BCBSIL individual plan with no more than a 63 day gap in coverage, you’ll have no pre-existing waiting periods.

For applicants with continuous prior coverage (no more than a 63 da gap) under an employer-sponsored plan, Blue Cross and Blue Shield of Illinois provides credit against the individual plan pre-existing condition exclusion waiting period.

For example, if you enroll in a Blue Cross and Blue Shield of Illinois “individual” plan after being continuously covered for 6 months under an employer group health plan, you’ll be considered to have satisfied 6 months of the 12 month pre-existing condition exclusion waiting period.

This exception works for maternity as well. If you were insured under an employer’s group health plan for a year or more, and you immediately enroll in a BCBSIL individual plan with the maternity option, you’ll have no waiting period for the maternity benefits as long as there is no more than a 31 day gap in coverage.

Medical Condition-Specific Waivers

If you have a condition, illness, or injury that can be identified as one that does not necessarily affect your overall good health but could affect the risk balance of all insureds, Blue Cross and Blue Shield of Illinois may exclude that condition from coverage. This means that expenses for treatment of that condition or any other condition related to it will not be covered for a specified period of time.

Blue Cross and Blue Shield of Illinois will place a maximum of two coverage exclusion riders on any one applicant. When a policy is conditionally approved with one or two exclusion riders, coverage will not be put in force until the applicant has accepted the offer by signing, dating, and returning the rider along with any other outstanding requirements that may be applicable.

Mental Health Counseling Guidelines

BCBSIL is extremely strict (and in our opinion, often unfair) on how they underwrite individuals whom have had mental health counseling. Individuals currently in counseling with a licensed therapist or psychologist will be automatically declined, regardless of the reason they are in counseling. BCBSIL will only consider accepting an individual after they have completed their treatment for at least 6 months, and acceptance will be based on the original diagnosis/reason for treatment. For example, an individual completing marriage counseling would most likely be accepted while an individual completing counseling for a drug addiction would not.

UPDATE: As of July 2011, BCBSIL no longer automatically denies individuals receiving mental health counseling and will approve most applicants on a case by case basis without issuing a pre-existing condition exclusion.

Medical Condition Rejection List

If you have a condition, illness, or injury that is listed on the Medical Condition Rejection List below, you will most likely be declined for individual coverage with Blue Cross Blue Shield of Illinois.

These conditions include, but are not limited to:

Adult Height & Weight Chart – Ages 19 and older

Below is a height and weight chart that lists BlueCross BlueShield of Illinois’ acceptable adult height and weight ranges.

• Individuals who have a normal body mass index (BMI) receive the standard premium rate.
• Individuals whose height and weight falls in the second column are still eligible for coverage, but will likely receive a 25% premium increase above the standard rate until their BMI falls within the normal range.
• Individuals who weigh more than the maximum allowed for their height will automatically be declined for coverage until additional Health Care Reforms go into effect on January 1, 2014.