GENERAL DESCRIPTION

Information Regarding Individual Plans: Pre-Existing Conditions

and the Washington State Standard Health Questionnaire

Important: The following definitions and examples are only general in nature and should not be construed to be any part of an insurance policy certificate. Only the policy certificate determines coverage benefits, limitations and exclusions.

Pre-Existing Conditions

A pre-existing condition is any medical condition, illness or injury that existed at any time prior to the Effective Date of coverage for which medical advice was given, for which a health care provider recommended or provided treatment, or for which a prudent layperson would have sought advice or treatment, within the six (6) months prior to the effective date.

Generally, no benefits are available for services or supplies furnished for any pre-existing condition (even if the condition worsens) during the first nine (9) months of coverage. This is called the pre-existing conditions waiting period.

For example, if a subscriber had not been diagnosed by a doctor or the symptoms of her pregnancy had not been evident, then the pregnancy would not be considered a pre-existing condition subject to the waiting period, even though she may have been pregnant at the time of application. As for pregnancy, keep in mind that prenatal care is not subject to the waiting period, regardless of when the enrollee became pregnant.

EXCEPTION: In many cases the period of time an enrollee was covered under their old policy will be credited toward their new plan's pre-existing condition waiting period. In all cases, deductibles and benefit maximums will start over. Time continuously covered under the previous individual policy will not be credited on the new policy if:

The break in coverage was greater than 63 days
The previous policy was not comparable in benefits (as determined by the new carrier) – see note at end of document.
The benefits under the previous policy provided lesser benefits than the new health plan

Organ Transplants Exception: Most carriers impose a 12-month waiting period for organ transplants with no credit for prior coverage. There may be exceptions to this limitation. Refer to carrier’s policy certificate for details.

The insurance carrier will determine whether a condition is a pre-existing condition subject to the waiting period on a case by case basis, taking into account the facts of the case.

Washington State Standard Health Questionnaire

This health questionnaire was created by the Washington State Health Insurance Pool (WSHIP). It is for people who apply for private, individual medical coverage with insurance carriers.

By completing this form, you will be giving your medical information to the insurance carrier. Your answers will determine if the insurance carrier will accept your application or if you will be referred to the Washington State Health Insurance Pool (WSHIP).

The insurance carrier will score your answers using a standard scoring system designed by WSHIP. The insurance carriers do not have control over the questions or the scoring system. If you are rejected for coverage and request an appeal, a carrier may then request further information. You may choose to supply this added information if you believe it will assist the carrier in scoring your questionnaire correctly.

The State Standard Health Questionnaire and information about the scoring system is available online. Currently applicants are allowed 299 points before being disqualified. The program was originally designed to allow approximately 92% of applicants to qualify. Applicants who are declined for coverage for health reasons can qualify for the Washington State Health Insurance Pool. Benefits and premium information are available online.

In most cases, you do not need to fill out a health questionnaire if you are:

Applying for coverage due to relocating within Washington state to an area where your prior health plan isn't offered.
Applying for coverage because your health care provider (whom you have seen in the past 12 months) has cancelled from his or her prior insurance, and is contracting with a new carrier you are applying for.
Applying for coverage after exhausting COBRA continuation coverage.
With some carriers, if applying for coverage for a newborn child or newly adopted child of an existing individual enrollee withi 60 days.
Applying for coverage due to loss of group coverage and your employer is not required to offer you COBRA. You must have had at least 24 months of continuous group coverage and you are enrolling within 90 days of the qualifying event.

You must apply for coverage within 90 days of relocation, provider cancellation or exhaustion of COBRA in order to have the Standard Health Questionnaire requirement waived.

Summary

State law provides that there can be no more than a 63-day break in coverage in order for any prior coverage to be credited against the pre-existing condition waiting period. State law also provides that applicants have 90 days to apply without having to complete the Standard Health Questionnaire from the time (a) COBRA is exhausted, (b) a provider leaves the current health plan, (c) the applicant is moving within Washington to an area in which their current coverage is not available, or (d) at least 24 months of group coverage was lost and the employer is not required to offer COBRA. These differing time periods may affect coverage depending on the date of the application.

For example, if someone was eligible for, elected, and exhausted COBRA continuation coverage and that continuation coverage had more benefits than the plan applied for, then the following table explains the consequence of applying at different times after the continuation coverage was exhausted.

# of Days from Date of Exhaustion of COBRA to Date of Application	Standard Health Questionnaire	Pre-existing Condition Waiting Period
1	Not Required	Credited
63	Not Required	Credited
64	Not Required	Not Credited
90	Not Required	Not Credited
91	Required	Not Credited

Note regarding prior coverage credit: The old carrier must provide a certificate of creditable coverage within 30 days of termination of policy and at no charge to you. If your coverage starts before the new carrier has a copy of your proof of coverage, pre-existing conditions will apply. However, generally once the new carrier receives the proof of coverage certificate from you they will waive or credit the pre-existing condition waiting period retroactively to your new coverage start date.

Important Note: It is always important to confirm the pre-existing condition rules, credible coverage determinations, and Standard Health Questionnaire procedures before applying for coverage and especially before terminating your prior coverage. Never terminate prior coverage before your new coverage has been approved.