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Pre-existing Conditions and Portability Regarding New Jersey Health Insurance Coverage

Pre-existing Conditions and Portability

Except as stated below for federally defined eligible individuals, if you have been uninsured for more than 31 days prior to the enrollment date (which means the effective date of coverage under the individual plan), you are subject to a 12-month waiting period for coverage of "pre-existing conditions."

A "pre-existing condition" is an illness or injury which manifests itself in the six months before the enrollment date and for which:

1. a person sees a doctor, takes prescribed drugs, receives other medical care or treatment or had medical treatment recommended by a doctor, or
2. an ordinarily prudent, or careful, person would have sought medical advice, care or treatment.

A pregnancy which exists on the date coverage begins is a pre-existing condition and will be subject to the limitations described above. However, certain complications of pregnancy will not be excluded for coverage as pre-existing conditions.

During the 12-month "pre-existing condition" waiting period, you will be covered for all conditions other than the pre-existing condition, subject to the terms of your contract or policy. After the "pre-existing condition" waiting period has ended, all illnesses and injuries -- including those related to the "pre-existing condition" -- will be covered subject to the terms of your contract or policy.

"Creditable coverage" is the term used under the federal Health Insurance Portability and Accountability Act of 1996 ("HIPAA") to define the types of prior coverage a person may have had. It is a very broad definition and includes, but is not limited to: individual and group plans, whether insured or self-funded, Medicare, Medicaid, and CHAMPUS. The individual plans contain a complete definition of "creditable coverage."

The "pre-existing condition" waiting period is waived for treatment of conditions which were treated or diagnosed and were covered under "creditable coverage" that terminated no more than 31 days prior to the effective date of your new individual plan.

The "pre-existing condition" limitation period is credited for time satisfied under for any "creditable coverage" provided there is no more than a 31-day lapse between your prior and your new coverage.

You will be required to provide your new carrier with proof of the prior "creditable coverage," so that the waiver or credit may be applied. Your prior plan should provide you with a certificate of creditable coverage to be used for such proof. If you do not have more than a 31-day lapse in coverage, you may change health plans without having to satisfy any new "pre-existing condition" waiting period. If you have only partially satisfied the "pre-existing condition" waiting period under prior coverage, you will have to satisfy only the balance of a "pre-existing condition" waiting period under your new coverage.

Exception: If an eligible person is a "federally defined eligible individual" the "pre-existing condition" waiting period requirement will only apply if there has been more than a 63-day lapse in coverage between the date the prior "creditable coverage" ends and the enrollment date. (For a federally defined eligible individual, the enrollment date is the date the person submits a substantially complete application for coverage.)

A "federally defined eligible individual" is defined as "a person who has been covered for at least 18 months without a break in coverage of 63 or more days under a group health plan, governmental plan, church plan, or health insurance coverage offered in connection with any such plan; who is not eligible for coverage under Medicare or Medicaid; and who does not have another health benefits plan, or hospital or medical service plan." The prior creditable coverage must not have been terminated, based on a factor relating to nonpayment of premiums or fraud. In addition, if the person was offered the option of continuation of coverage under a COBRA continuation provision or similar State continuation option, the person must have elected and exhausted that continuation coverage.