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Your First Year on The Plan

  Your First Year on The Plan 

Questions and Answers Concerning Coverage
During Your First Year On The Plan
Prepared By
The Employee Benefit Service Center


Q     I was recently hired and want to be covered under my employers benefit plan. Can I be covered right away?
A    
Most plans have a waiting period, or time period during which you are a full-time active employee, before your coverage begins. The waiting period is listed in the Summary Plan Description. Once the waiting period expires, you can enroll in the Plan and become covered immediately. However, services for pre-existing conditions may not be covered during the first twelve months of your coverage
 
Q      When should I enroll in the Plan?
A  
    You should enroll in the Plan within 31 days after your eligibility date. Your eligibility date is the date the waiting period ends. If you do not enroll yourself or any dependents during the 31 day time period, and you or your dependents want to enroll at a later date, there may be limited time periods when you or your dependents can enroll later and there may be a longer time period when pre-existing conditions are not paid after enrollment.
Please review the definition of a dependent before enrolling them in the Plan. The definition is outlined in the Summary Plan Description.  

    What is a pre-existing condition?
A
      A pre-existing condition is a medical condition for which you received treatment or advice to be treated from a medical care provider during the six months before your hire date. If you are taking prescription drugs for a condition, that is considered to be treatment for a condition.

    When would a pre-existing condition be covered during the first twelve months of coverage?
A
     A pre-existing condition would be covered for all or part of the first twelve month’s of coverage if you were covered on another medical plan 63 days or less before your hire date.

For example: If your hire date was July 1, your other coverage would have to end later than March 30 for it to be considered as creditable coverage (or coverage that counts).

The number of days from March 30 to July 1 is calculated as follows:
     March = 2 days,
     April = 30 days,
     May = 31 days...
     for a total of 63 days. 

Q     If I had coverage on another medical plan within the 63 day time period, how does that help my pre-existing condition get covered during the first twelve months of coverage?
A     If you had coverage within the 63 day time period described above, the time period you had that coverage directly reduces the time period that your pre-existing conditions are not covered. For example, if you had coverage for five months, your pre-existing time period would be only seven months. This is calculated by subtracting five months (the period of your creditable coverage) from twelve months (the total pre-existing condition limitation time period). In this example, your pre-existing condition would not be covered under the Plan for the first seven months, but would be covered from that date forward. 

Q     What if I had coverage within the 63 day time period described above, and the coverage was for a time period of more than twelve months?
A
     Is this situation, you would have twelve months of creditable coverage, and when subtracted from the twelve months of total pre-existing condition limitation time period, there would be no pre-existing condition limitation period (12-12 = 0). You would be covered for your pre-existing condition upon enrolling on the Plan. 

    How can I show that I was enrolled in a Plan within the 63 day time period before my hire date?
A     Your previous Plan, by law, must provide you with a “Certificate of Creditable Coverage” that you can provide when you enroll in this Plan. This certificate documents the coverage time periods for you and each dependent and can be used to verify that the coverage ended within the 63 day time period and the length of time of the coverage. 

    What if I did not get the Certificate of Creditable Coverage or what if I lost it?
A
     Your previous benefit plan is required by law to provide the certificate upon terminating coverage. You may also obtain a certificate by request, if the request is within 24 months after you lose coverage under a plan, even if the certificate was previously provided to you. You also have the right to demonstrate creditable coverage through the presentation of other documentation, including bills or ID cards, explanation of benefit statements, or third party statements in writing or by phone. 

Q     I changed jobs a lot and had coverage from three different plans in the past year. Will all of them count toward my creditable coverage?
A
     If there was never more than a 63 day gap between coverage, all three would count toward creditable coverage. If there was more than a 63 day gap in coverage, all coverage before the 63 day gap would not count. 

    I noticed in question number 2 above, that if I do not enroll on time there may be some restrictions on enrolling later. What are these restrictions?
A
     If you declined to enroll during your initial enrollment period, and later want to enroll, there are some restrictions. You are only allowed to enroll during the open enrollment time period held annually. For example, if you decide to enroll in June and the open enrollment time period is in December, you must wait until December before you can enroll in the Plan. The open enrollment time period is listed in your Summary Plan Description.
When you enroll late during the open enrollment time period, there is also a different pre-existing limitation time period. While on-time enrollees have a maximum of twelve months when pre-existing conditions are not paid, late enrollees have a maximum of eighteen months when pre-existing conditions are not paid.  

   What if I have coverage on my spouse’s plan when I am asked to initially enroll and therefore waive coverage under this Plan and later lose the coverage on my spouse’s plan. Will I have to wait until the open enrollment time period to enroll?
A
     When you decline coverage during your initial enrollment period because you have coverage elsewhere and later lose that coverage, you might have special enrollment rights. To have special enrollment rights, you must have lost coverage on the other plan as a result of losing eligibility or after cessation of employer contributions for the other coverage. If you lose coverage as a result of the failure to pay your premiums or for cause (such as making a fraudulent claim), you do not have special enrollment rights.
If the other coverage is COBRA continuation coverage, the special enrollment rights can only be requested after exhausting COBRA benefits. However, you do not have to elect COBRA to preserve the special enrollment rights.
If you have special enrollment rights, you must enroll within 31 days of the event leading to your special enrollment rights. Coverage will begin the first day of the month following the request to enroll and you do not have to wait for the open enrollment time period.
Another advantage of having special enrollment rights is that there is a maximum of twelve months when pre-existing conditions are not paid. Of course, this period will be reduced by any creditable coverage. 

   If I get married or have a child, do I have to wait until the open enrollment time period before I can enroll by new dependents?
A
    Special enrollment rights are granted for birth, marriage, adoption, or placement for adoption. The election to enroll must be made within 31 days following the birth, marriage, adoption, or placement for adoption. Changes in family composition trigger the special enrollment rights. For example, the special enrollment rules allow an eligible employee to enroll when he or she marries or has a new child (as a result of marriage, birth, adoption, or placement for adoption). A spouse of the employee can be enrolled separately at the time of marriage or when a child is born, adopted or placed for adoption. 

    I am pregnant and just enrolled on the plan. Will my pregnancy be considered pre-existing?
A
     Pregnancy is never considered pre-existing, so you will be covered for your pregnancy and the birth of the child.  

   Are there any other situations where pre-existing limitations are not applied?
A
    There are no pre-existing condition exclusions applied to a newborn, an adopted child under age 18, or a child placed for adoption under 18, if the child becomes covered within 31 days of the birth, adoption, or placement for adoption. This exception applies one time and in the future, there may be pre-existing conditions if there is a break in coverage of more than 63 days. 

Q     I do not have a certificate of creditable coverage because I did not have coverage within the 63 day time period. However, I do not have a pre-existing condition. Can I assume that my claims for medical services will be paid without any question about the pssibility of my conditions being pre-existing condition?
A     The claims administrator does not have a record of your medical condition or the treatments or advice for treatment during the six months before your hire date. When claims are received, the claims administrator will review them to screen for certain conditions that are frequently pre-existing. If one of these conditions appears, they will deny the claim and ask that you contact your physician for medical records. The physician can forward medical records to the claims administrator or a letter that confirms that the condition did not exist before your hire date. Once this information is received, the claim will be completed. This process may have to be done for more than one physician if you have claims from more than one physician that fit the profile of a possible pre-existing condition.
 


Notice: This information is prepared exclusively for the use
of clients of
The Employee Service Center

Longtime member of the Society of Professional Benefit Administrators (SPBA)

SAS 70 compliant


 
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