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How to claim creditable coverage

How to claim creditable coverage

Old Jul 20th 2013, 8:26 pm
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Default How to claim creditable coverage

Dear friendly expats,

I am moving to Boston in 11 days (argh!/yay!) on a J-1 visa to take a twelve month research post. It's UK funded so I don't qualify for employee insurance and have paid for a J-1 fulfilling insurance plan from HarbourGroup insurance. They have said that they don't cover pre-exisiting conditions for 12 months, (which I do have, alas) but they also describe creditable coverage.

If I get a letter from my GP saying I have NHS-cover, yadayadayada.... Then can I make the insurer give me some sort of letter stating they WILL cover my pre-exsitings?

The wording in the contract is as follows..

"Pre-existing Condition means any condition for which medical
advice or treatment was received or recommended within the six
months immediately preceding Your effective date of coverage.
This exclusion applies for 12 months after Your effective date of
coverage. This exclusion does not apply to a pregnancy existing
on Your effective date of coverage. This policy shall credit the
time You were previously covered under a previous health insurance
plan or policy or employer provided health benefit arrangement,
if the previous coverage was continuous to a date not
more than 63 days prior to the effective date of the new coverage.
Such credit shall apply to the extent that the previous coverage
was substantially similar to the new coverage. The
creditable coverage outlined above means any prior health care
coverage as defined in HIPAA which includes group coverage;
individual coverage; Medicare; Medicaid; military service related
care; Indian health service or tribal organization coverage; state
health benefits risk pool; a public program offered under the Federal
Employees Health Benefits Program: a public health plan:
and Peace Corps Act Health Plan; state children’s health plans
(S-CHIP); and foreign national health plans (this includes those
health plans maintained by foreign governments, not just insurance
coverage through a carrier in a foreign jurisdiction)."


How shall I proceed?

Thanks very VERY much,

Best wishes,
Athalia
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Old Jul 20th 2013, 10:21 pm
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Default Re: How to claim creditable coverage

You don't really need to do anything unless or until you either make a claim and it is denied because the insurer believes that it was a preexisting condition or they specifically ask you for evidence of prior creditable coverage.

If and when that happens you tell them that immediately before being enrolled in their plan you were resident in the UK and covered by the NHS. Often that is sufficient. If they want more evidence than that then you need to find out exactly what it is that they *do* want. I'm not sure that a letter from your GP in the UK would be either necessary or sufficient.
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Old Jul 21st 2013, 2:45 am
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Default Re: How to claim creditable coverage

Originally Posted by md95065 View Post
You don't really need to do anything unless or until you either make a claim and it is denied because the insurer believes that it was a preexisting condition or they specifically ask you for evidence of prior creditable coverage.

If and when that happens you tell them that immediately before being enrolled in their plan you were resident in the UK and covered by the NHS. Often that is sufficient. If they want more evidence than that then you need to find out exactly what it is that they *do* want. I'm not sure that a letter from your GP in the UK would be either necessary or sufficient.
Pretty much this but it sounds like maybe md95065 hasn't had to deal with the nightmare of having things not covered and needing to prove creditable coverage. If you need something, like medical equipment or drugs, that are expensive and you can't get them because the insurance refuses to pay you either have to rush to get the pre-existing condition clause removed in order for them to cover it or you have to pay out of pocket for them and then work everything out then submit a claim for reimbursement. Depending on what it is you could be looking at thousands of dollars. Last year I switched insurance and a similar thing happened to me and I was looking at a $1,200 bill for stuff I needed that should have been completely free. Luckily I had already requested a letter from my prior insurance company so even though I got a denial letter from my new insurance company I had already sent in enough proof to get the decision reversed. If I had waited it would have been a stressful and expensive situation.

If you get a letter from your GP saying you were covered under the NHS for X number of years then call your insurance company and get the fax number, or secure email address, of the department you need to send it to and then send it. You likely won't get any sort of confirmation other than claims not being denied although a customer service rep should be able to confirm that the clause has been removed. I would recommend doing it sooner rather than later because it's just easier when you have medical conditions and need things associated to them.
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Old Jul 21st 2013, 3:01 am
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Default Re: How to claim creditable coverage

Originally Posted by md95065 View Post
You don't really need to do anything unless or until you either make a claim and it is denied because the insurer believes that it was a preexisting condition or they specifically ask you for evidence of prior creditable coverage.

If and when that happens you tell them that immediately before being enrolled in their plan you were resident in the UK and covered by the NHS. Often that is sufficient. If they want more evidence than that then you need to find out exactly what it is that they *do* want. I'm not sure that a letter from your GP in the UK would be either necessary or sufficient.
You have to declare your preexisting conditions at time of application and this determines whether you are in a high risk pool, the premium cost, and the coverage. If you don't declare preexisting conditions, the insurer will likely not pay.
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Old Jul 21st 2013, 3:38 am
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Default Re: How to claim creditable coverage

Originally Posted by Michael View Post
You have to declare your preexisting conditions at time of application and this determines whether you are in a high risk pool, the premium cost, and the coverage. If you don't declare preexisting conditions, the insurer will likely not pay.
You may well be correct but it was my impression (based on vague memories of the last time that I completed such an application) that group plans didn't normally ask about preexisting conditions up front (and I was also assuming that the plan the the OP would be joining was some kind of group plan).
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Old Jul 21st 2013, 3:46 am
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Default Re: How to claim creditable coverage

Originally Posted by Duncan Roberts View Post
.. but it sounds like maybe md95065 hasn't had to deal with the nightmare of having things not covered and needing to prove creditable coverage ...
Unfortunately I have had to deal with exactly that issue in relation to about $80,000 worth of hospital bills, but "fortunately" those problems were all after the fact and just concerned who would end up paying the bills ...

The whole thing took about 6 weeks to sort out and required 3 or 4 letters and hours on the phone with them
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Old Jul 21st 2013, 4:30 am
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Default Re: How to claim creditable coverage

Originally Posted by Athalia View Post
They have said that they don't cover pre-exisiting conditions for 12 months
Not sure if this helps you, but if you're covered by HIPAA, then the insurer can only look back at pre-existing conditions for the six previous months.

http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html
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Old Jul 21st 2013, 6:42 am
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Default Re: How to claim creditable coverage

I directed the OP here (Waves!)

Can anyone locate tracym's fantastic thread started in (approximately) 2008 or 2009?

I've searched and searched all over the forum, but can't find it.

Thanks!
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Old Jul 21st 2013, 6:44 am
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Default Re: How to claim creditable coverage

Originally Posted by md95065 View Post

If and when that happens you tell them that immediately before being enrolled in their plan you were resident in the UK and covered by the NHS. Often that is sufficient. If they want more evidence than that then you need to find out exactly what it is that they *do* want. I'm not sure that a letter from your GP in the UK would be either necessary or sufficient.
It was for a number of us on the forum in 2008-2011, but I can't find the those threads on here.

BW
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Old Jul 21st 2013, 10:11 am
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Default Re: How to claim creditable coverage

Thanks to everyone for replying so quickly!

Hi there "Ozziedoc" wink wink! - Thanks for introducing me to the colossus of information here!

I'm going to see if I can get confirmation that the clause can be/is removed before I travel. But I'm a bit worried about the line that says substantially similar coverage - does this mean they can get out of covering me by saying that the cover was not similar?

10 days till I fly! YAY!
Any Bostonian expats out there??
Best wishes,
Athalia
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Old Jul 21st 2013, 12:58 pm
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Default Re: How to claim creditable coverage

Originally Posted by Athalia View Post
Thanks to everyone for replying so quickly!

Hi there "Ozziedoc" wink wink! - Thanks for introducing me to the colossus of information here!

I'm going to see if I can get confirmation that the clause can be/is removed before I travel. But I'm a bit worried about the line that says substantially similar coverage - does this mean they can get out of covering me by saying that the cover was not similar?

10 days till I fly! YAY!
Any Bostonian expats out there??
Best wishes,
Athalia
Possibly.....but your current cover is equal to or better than what they'll propose
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Old Jul 21st 2013, 2:29 pm
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Default Re: How to claim creditable coverage

Originally Posted by Ozzidoc View Post
I directed the OP here (Waves!)

Can anyone locate tracym's fantastic thread started in (approximately) 2008 or 2009?

I've searched and searched all over the forum, but can't find it.

Thanks!

Not a thread but this is the info Tracey sent me back in 2009:

The HIPAA final rule:

http://www.dol.gov/federalregister/P...px?DocId=10270

The rule was changed to specifically include foreign government plans such as the NHS. Also, it specifically says that a a certificate of creditable coverage is NOT required - just some reasonable proof (e.g. national insurance card, letter from doctor, etc.)

Search the document for the word "foreign" for applicable text.

Shorter version - here is a comment from Blue Cross/Blue Shield, which specifically mentions that the the law changed to include plans such as the NHS as creditable coverage.

http://www.bcbsil.com/PDF/legislative_update_405.pdf

FAQs address the fact that a doctor's letter or some such can suffice if a certificate of creditable cover is not available:

http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

I have gotten this to work with a private insurer, and also for another person, it was accepted by a state high risk pool.

I believe it used to be a problem, but now the law has changed. Sometimes one has to point out the law, as not all insurers are aware of it (the state high risk pool wasn't) - but they were glad to oblige once it was pointed out to them.

I hate to see ths as an ongoing issue - as I do truly believe it is ok now.
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Old Jul 22nd 2013, 5:22 pm
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Default Re: How to claim creditable coverage

What the insurance company want to see will be up to them. A letter from GP or health authority is usually enough, but you need to ask them first what they will accept.

Worse comes to worst, you might be able to get on the MA Health plan, though I thought you had to be a MA resident for 12 months to first qualify, some people have said they haven't needed that but it affected the rate.
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