HIPAA vs. "initial enrollee", "timely enrollee", &

[Guest Scott Fielding]

How would you handle this employee's eligibility? Hire date 10-15-99, waived coverage when initially offered. Had proof of other coverage from May '01 to Sept '01, enrolled in company plan at open enrollment Oct 1 '01. Would there be any pre-x?

[Sandra Pearce]

Using HIPAA guidelines the plan can exclude coverage for pre-existing conditions (HIPAA specific definition) unless the person has 18 months of creditable coverage (without a significant break in coverage - also HIPAA specific definition). Prior carrier should be able to provide certification of period of coverage. Since the person has only provided a certificate with 5 months of coverage you should only give him credit for 5 months. Additional proof should be obtained for the period prior to May 2001.

[GBurns]

Aside from any HIPAA issues, What does your plan say regarding pre-xs? Outside of self-funded plans and small group plans, I do not remember having seen a pre-ex in a group plan for quite some time.

[Sandra Pearce]

We have a self funded group health plan that uses the maximum pre-existing limitations - look back of 6 months, pre-ex excluded for 12 months.

[Mary C]

We are a large multi-state company that is almost exclusively insured managed care options under our plan and several of our POS options do have pre-ex exclusions written into them.

[Jbentz]

When you look at the remaining seven in question, do not forget to irequest information regarding waiting periods. These are not considered a break in coverage and can really change the outcome of the pre-existing time period.