This section is a synopsis of the information found in the certificate language and within this Pre-Ex Document. To see the full details, please read the certificate and this entire Pre-Ex Document.

On our Retail plans, claims for pre-existing conditions are not covered during the first six months of the policy. A pre-existing condition is defined as any injury or sickness whether diagnosed or undiagnosed, for which a covered person received medical care or treatment within the 6-month period leading up to the effective date of his or her supplement insurance.

When the date of service on a claim is within the first 6 months of coverage, the claims examiner must determine whether or not the condition is pre-existing. This determination is made by reviewing the insured’s medical records. First, we will need the member to complete and sign the authorization section of a claim form. The Claims Department will send claim forms to the member for this purpose. After the signed form is returned, the Claims Department writes to the physician(s) to request the records. After the medical records are received, the Claims Department is able to identify the pre-existing conditions. Please see this section for more details on how the Pre-Ex Limit may affect the processing of claims.

The pre-existing conditions limitation only applies to the Retail (non-employer) members. Corporate/employer plans do not have a pre-existing conditions limitation.

PRE-EXISTING CONDITION LIMITATION

The Certificate of Insurance defines pre-existing condition as follows:  

Pre-Existing Condition Defined:

Pre-Existing Condition, as used in this limitation, means any Injury or Sickness, diagnosed or undiagnosed, for which Medical Care is received by a Covered Person:

(a) within the 6 month period prior to the Covered Person’s effective date of insurance; or

(b) with respect to the limitation for increase in coverage, within the 6 month period prior to the effective date of the Covered Person’s increase in coverage.

For the purposes of this limitation, we will consider:

(a) Medical Care received when:

(1) a Physician is consulted or medical advice is given; or

(2) Treatment is recommended or prescribed by, or received from, a Physician;

(b) Treatment to include, but not limited to, any:

(1) medical examination, test, attendance, or observation;

(2) medical services, supplies, or equipment, including their prescription or use; or

(3) prescribed drugs or medicines, including their prescription or use.

All manifestations, symptoms, or findings which result:

(a) from the same or related accident or Sickness; or

(b) from any aggravations of accident or Sickness;

are considered to be the same accident or Sickness for the purposes of determining a Pre-Existing Condition.

Conditions Prior to Effective Date: During the first 6 months of a Covered Person’s insurance, losses incurred for Pre-Existing Conditions are not covered. This will not apply to loss that the Covered Person incurs after being free of Medical Care for the condition for a six month period (ending any time on or after the Covered Person’s effective date).

Conditions Prior to Effective Date of Increase in Coverage: During the first 6 months following the date a Covered Person makes a change in coverage that increases the Covered Person’s benefits, the increase will not be paid for Pre-Existing Conditions. This will not apply to loss that the Covered Person incurs after being free of Medical Care for the condition for a six month period (ending any time on or after the effective date of increase).

STATE MANDATES AFFECTING PRE-EXISTING CONDITION LIMITATIONS

CALIFORNIA

Credit for Time Satisfied under Prior Policy: If the Policy replaces another policy supplementing TRICARE, we will give credit for time satisfied by a Covered Person under that prior policy for satisfaction of the Pre-Existing Condition look-back period of 6 months under the Policy.

NEW YORK

This Pre-Existing Condition limitation will be considered satisfied to the extent it was satisfied under previous Creditable Coverage, if the previous Creditable Coverage was continuous to a date up to 63 days prior to the effective date of the new coverage.

Creditable Coverage means coverage of the Covered Person under any of the following: 

1) A group health plan;

2) Health insurance coverage; 

3) Part A or Part B of Title XVIII of the Social Security Act; 

4) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928; 

5) Chapter 55 of title 10, United States Code; 

6) A medical care program of the Indian Health Service or of a tribal organization; 

7) A state health benefits risk pool; 

8) A health plan offered under Chapter 89 of Title 5, United States Code; 

9) A public health plan (as defined in regulations); 

10) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504(e).

NORTH CAROLINA

The Certificate of Insurance states the following:

Pre-Existing Condition, as used in this limitation, means any Injury or Sickness for which medical advice, diagnosis, Medical Care or treatment was received or recommended within the 6 month period prior to the Covered Person’s effective date of insurance. 

Conditions Prior to the Effective Date: After the first 6 months of a Covered Person’s insurance, losses incurred for Pre-Existing Conditions are covered. 

MAINE

Residents of the State of Maine are not subject to pre-existing condition limitations. 

OREGON

Pregnancy will not be subject to a Pre-Existing Condition Limitation, nor may such limitation be applied to newly born and adopted children, under age 18, added to coverage under the Policy within 31 days of birth or placement for adoption.

SOUTH CAROLINA

Losses incurred for Pre-Existing Conditions are not covered until:

1. 6 consecutive months have elapsed during which no medical treatment or advice is given by a

    physician for such condition; or

2. the Covered Person has been insured under this Policy for 6 consecutive months, whichever    

    occurs first. 

However, whenever a Covered Person moves from one insured group to another, the insurer of the group to which the Covered Person moves shall give credit for the satisfaction of the pre-existing condition limitation period or portion thereof already served under the prior coverage if the coverage is selected when the person first becomes eligible and the coverage is continuous to a date not more than thirty days prior to the effective date of the new coverage, exclusive of any applicable waiting periods.

VIRGINIA

Pre-Existing Condition Defined:

Pre-Existing Condition, as used in this limitation, means any Injury or Sickness, diagnosed or undiagnosed, for which Medical Care is received by a Covered Person within the 6 month period prior to the Covered Person’s effective date of insurance.

For the purposes of this limitation, we will consider:

  (a) Medical Care received when:

(1) a Physician is consulted or medical advice is given; or

(2) treatment is recommended or prescribed by, or received from, a Physician;

  (b) Treatment to include, but not limited to, any:

(1) medical examination, test, attendance, or observation;

(2) medical services, supplies, or equipment, including their prescription or use; or

(3) prescribed drugs or medicines, including their prescription or use.

All manifestations, symptoms, or findings which result:

  (a) from the same or related accident or Sickness; or

  (b) from any aggravations of accident or Sickness;

are considered to be the same accident or Sickness for the purposes of determining a Pre-Existing Condition.

Losses incurred for Pre-Existing Conditions are not covered until:

1.6 consecutive months have elapsed during which no medical treatment or     

       advice is given by a physician for such condition; or

2.the Covered Person has been insured under this Policy for 12 consecutive   

       months, whichever occurs first.

10/1/04 ENHANCEMENT TO PRE-X CONDITION LIMITATION WAIVER

* Must submit copy of DD-214 showing retirement date

**Must be involuntary termination from a non-TRICARE Supplement Employer group plan. Must submit copy of Certificate of Creditable Coverage or Certificate of Prior Group Health Plan showing termination date. Ineligible for waiver if prior coverage was terminated due to member’s request. 

WAIVER OF PRE-EXISTING CONDITION LIMITATION

Waiver for Conditions Prior to Effective Date of Coverage: Under the following conditions, the period of time required to satisfy the Pre-Existing Condition exclusion will be reduced or waived as stated:

If you retire from Active Duty and become eligible for TRICARE Retiree Supplement coverage as provided under “Plan Conversions” and Request such coverage within 63 days of the date you first become eligible for coverage, we will credit you with continuity of coverage from your prior effective date under the Active Duty Family Supplement.

See attached Enhancement to the Pre-existing Condition Limitations.

CONDITIONS UNDER WHICH PRE-EXISTING LIMITATION MAY BE WAIVED.

Waiver for Conditions Prior to Effective Date of Coverage:  Under the following conditions, the period of time required to satisfy the Pre-Existing Condition exclusion will be reduced or waived as stated in the Certificate of Insurance. Refer to the 10.1.2004 Enhancement to the Pre-existing Condition Limitations for more information.

Military Retirement

“If a member who retires from Active Duty becomes eligible for TRICARE Supplement coverage as provided under “Plan Conversions” and Requests such coverage within 63 days of the date he or she becomes eligible for the coverage, we will credit the person with continuity of coverage from his or her prior effective date under the Active Duty Family Supplement”.

Involuntary Termination from an Employer Group Plan

If an individual has an involuntary termination from an employer group plan and enrolls in the supplement plan within 30 days following the termination of the prior group plan, the pre-existing condition limitation may be waived. To qualify for waiver, the individual must submit a copy of the Certificate of Creditable coverage indicating the names of the individuals covered under the prior plan, name of the prior plan and the termination date.

EXAMPLES OF VOLUNTARY AND INVOLUNTARY TERMINATION

Pre-Ex will be waived if the termination is Involuntary. Enrollment must be within 30 days of loss of OHI coverage.

INVOLUNTARY TERMINATION

- If an employee retires and through retirement loses insurance coverage.

- Loses insurance due to retirement and elects not to continue under COBRA.

- COBRA exhausted. 

Pre-Ex will not be waived if the termination is Voluntary. 

VOLUNTARY TERMINATION

- Chooses to terminate insurance plan due to the high cost (including COBRA).

- Retires from employment but chooses to terminate employer’s retirement plan (Example, federal employees who retire are eligible to continue under the Federal Employees Health Benefits Plan (FEHBP). If they do not want to continue coverage, they must formally choose to suspend FEHBP).

- Enrolled in COBRA and chooses to terminate COBRA prior to exhausting COBRA benefits.

ADDITIONAL CONDITIONS UNDER WHICH PRE-X WILL NOT BE WAIVED

1. Pre-x is not waived for members who re-enroll to avoid the higher premium cost of their current supplement plan. 

2. Pre-x is not waived for corporate members who switch to a retail plan. 

3. Pre-x is not waived for members who have a break in coverage unless premium is paid up to avoid the break.

TELEPHONE INQUIRIES

Under certain conditions, the pre-existing condition limitation may be waived. When callers request information regarding waiver of the pre-existing condition limitation, please refer to the Requirements for Waiver of the Pre-x Limitation. Please note that the pre-x limitation is not automatically waived just because an individual had continuous prior insurance coverage. That may apply to residents of California and North Carolina only (see information above on state mandates). Note also that pre-x limitation does not apply to residents of Maine. For residents of all other states the waiver criteria described below must apply.

Callers who inquire about waiver of pre-existing condition limitation should not be informed that the pre-x limitation would be waived. We should not be giving any guarantees over the telephone. Instead callers should be informed of the conditions under which the limitation may be waived and should be advised to submit documentation for our review. We will make the determination regarding waiver following receipt and review of the documentation provided.

TRICARE PRIME TO TRICARE STANDARD CONVERSION

TRICARE Prime to TRICARE Standard/Extra Supplement Conversion: When a Covered Person becomes disenrolled from TRICARE Prime, his/her coverage under the TRICARE Prime Supplement will terminate. 

Under certain circumstances, the person may apply for coverage under the TRICARE Standard/Extra Supplement. We will credit his/her Pre-Existing Condition Exclusion for the period covered by the TRICARE Prime Supplement. To qualify, the Covered Person must have been continuously covered under a TRICARE Prime Supplement for a minimum of one year immediately before the disenrollment. This one year requirement will not be applied if: 

a)       the person disenrolled because he or she moved to a residence located outside the network’s area; or

b)      the person was covered under a Prior Supplement.

However, it will apply when a person is disenrolled because specialty care for their medical condition is not available in the network. In addition, to qualify the Covered Person must apply within 60 days of disenrollment. 

In all other circumstances, the TRICARE Supplement coverage will be subject to satisfaction of the Pre-Existing Condition limitation. These would include situations where: 

a)       the Covered Person does not make timely application or does not meet the minimum one year prior coverage requirement; 

b)      the Covered Person voluntarily disenrolls prior to the end of the annual TRICARE Prime coverage period, whether through non-payment of TRICARE Prime fees, or for the purpose of procuring a higher level of coverage from TRICARE for treatment from an out-of-network provider, or for any other reason. 

TRICARE STANDARD/EXTRA TO TRICARE PRIME CONVERSION

TRICARE Standard/Extra Supplement to TRICARE Prime Supplement Conversion: If, while covered by a TRICARE Standard/Extra Supplement, a person enrolls in TRICARE Prime, the TRICARE Standard/Extra Supplement will terminate and coverage will be transferred to a TRICARE Prime Supplement plan of his/her choice. The Pre-Existing Condition Exclusion will be credited for the period covered under the TRICARE Standard/Extra Supplement Plan. Covered Expenses incurred under TRICARE Prime will only be payable under the terms of the TRICARE Prime Supplement. The Covered Person must give us written notice of TRICARE Prime enrollment as soon as possible, but at least within 60 days. 

HOW TO WAIVE THE PRE-EXISTING CONDITION LIMITATION

Pre-x is waived under the following conditions:

Members who enroll in the plan within 30 days of an involuntary termination from an employer group plan (not a TRICARE Supplement Plan). A termination is not involuntary if the member is the one who request to have the coverage cancelled. (Example of involuntary termination: If a member’s insurance has cancelled because the member left employment).

Also refer to state mandated benefits for California, New York and South Carolina residents.

Military Retirement 

Pre-x is waived for Members who enroll in the plan within 63 days of retirement following military retirement. (Request copy of DD-214 showing military retirement date). If the member submits his/her DD-214 for consideration of waiver of the pre-existing limitation, process as follows:

1. Compare the military separation date to the coverage effective date to determine if the 63 day requirement is met.
2. If the effective date is within the 63 day period (following military retirement date), pre-x is waived
3. Add comment to Note and Claims Adjudication Note screens stating that the pre-existing condition limitation has been waived due to enrollment in the supplement plan within 63 days of military retirement date.
4. Send waiver of pre-x waiver confirmation letter (see Letter Templates).
5. Inform Claims Specialist that the pre-x limitation has been waived for this member/dependent.

Involuntary termination of an Employer Group Plan

Following receipt of the Certificate of Creditable coverage (also known as Certificate of Prior Group Health Plan):

1. Review Certificate to determine if prior coverage was an employer group plan. Please note that pre-x is not waived if the prior coverage is an individual plan, Medicaid or a state health programs such as Children’s Health Insurance Program (CHIP).
2. Verify that the individual seeking waiver of pre-x is named on the Certificate of Insurance.
3. Verify that the Certificate indicates the termination date of coverage. If coverage is still active, pre-x should not be waived.
4. Add comment to Note and Claims Adjudication Note screens stating that the pre-existing condition limitation has been waived due to enrollment in the supplement plan within 63 days of military retirement date.
5. Send waiver of pre-x waiver confirmation letter (see Letter Templates).
6. Inform Claims Specialist that the pre-x limitation has been waived for this member/dependent.

TRICARE Reserve Select 

Pre-x is waived for TRICARE Reserve Select (TRS) Supplement Plan members whose enrollment is within 30 days of the effective date of their TRS coverage.  

1. TRS members are asked to indicate the effective date of their TRS coverage on their supplement plan enrollment form. 
2. The pre-x limitation may be waived if the supplement plan effective date is within 30 days of enrollment in TRS. 

In some cases, the pre-existing conditions limitation can be waived or shortened. Please see the following sections for details on when and how this may be done.

Pre-Existing Conditions Limitation Period – Other Rules

Other Rules that Waive or Shorten the Pre-Ex Period

This section is a synopsis of the information found in the certificate language and within this Pre-Ex Document. To see the full details, please read the certificate and this entire Pre-Ex Document.

The pre-existing conditions limitation can also be waived or shortened under certain situations, regardless of the insured’s state.

If documentation/proof of any kind is needed from the insured, he/she should send such documentation along with a letter asking that the pre-ex limit be waived.

In some cases, the applicant does not need to submit documentation. For example, persons enrolling in a supplement within 30 days of moving from Active Duty to TRS do not need to send us anything. In these cases, if it appears that pre-ex should have been waived but it was not waived, the CSR may email a request for review to his/her supervisor.

When callers request information regarding waiver of the pre-existing conditions limitation, CSRs should explain the conditions under which the limitation may be waived and advise the caller to submit documentation for our review. We will make determinations following receipt and review of the documentation requested. We should never verbally guarantee waiver.

Retiring from Active Duty:

Members who enroll within 63 days of the sponsor’s retirement from Active Duty can request the pre-ex limitation be waived.

Applicants need to submit a copy of the DD-214 retirement papers along with the application for coverage.

Moving from Active Duty to TRS: 

Members and/or dependents who enroll for a TRS supplement plan within 30 days of the member’s transition from Active Duty to TRS (National Guard / Reserve) can request the pre-ex limitation be waived by listing the TRS enrollment date on the supplement application.

No additional documentation is needed.

Moving from Prime to  Select: 

Under certain circumstances, we will credit the pre-ex limit when a member switches from our Prime supplement to our Select supplement. To qualify, the member must apply for the Select plan within 60 days of disenrollment from Prime and must have been continuously covered under our Prime supplement for a minimum of one year immediately before the disenrollment. This one year requirement will not be applied if the person dis-enrolled because he or she moved to a residence located outside the network’s area. 

The one year requirement applies in all other situations, including but not limited to: failure to pay the Prime fees, dropping Prime to procure a higher level of coverage from an out-of-network provider, dropping Prime because a specialist is not available in the network.

No documentation is needed.

Moving from Select to Prime: 

If a member is covered under our Select supplement plan and moves to our Prime supplement plan, the pre-ex period will be credited for the period covered under the Prime supplement plan, as long as there is no break in coverage.

No documentation is needed.

Moving from TRS to Prime:

If a member is covered under our TRS supplement plan and moves to our Prime supplement plan, the pre-ex period will be credited for the period covered under the Prime supplement plan, as long as there is no break in coverage.

No documentation is needed.

Involuntary Termination of an Employer Group Plan:

Pre-Ex is not waived for voluntary termination of an employer group plan.

Voluntary termination includes the following:

• Lapsing for non-payment
• Failure to elect or renew coverage
• Early termination/lapse of COBRA
• Failure to elect COBRA, when available as an option
• Termination of the plan by request
• Failure to elect, maintain, or renew a retiree policy

However, if a member is involuntarily terminated from an employer group plan and enrolls in our supplement plan within 30 days of the termination date (or within 30 days of COBRA ending), our pre-ex period will be waived. If COBRA is an option, COBRA must first be utilized for the maximum period of time allowable.

Involuntary termination includes the following:

• Retirement
• Resignation from employment
• Termination of employment by the employer
• Change in eligibility due to reduction in work hours
• Employee called to active duty
• Spouse and/or child losing coverage due to employee becoming eligible for Medicare, or due to divorce, legal separation, or death of the employee
• Child losing coverage due to loss of dependent status

Applicants wishing to waive pre-ex must provide all required information/proof. This includes the termination date, reason for termination, and proof that COBRA was exhausted, if applicable. This information must be in writing from the prior insurance company or from the employer group. Sometimes, all of this information is not included on a Letter of Creditable Coverage. When this is the case, the member must request additional documentation from the prior carrier/group.

Conditions Under Which Pre-Ex will NOT Be Waived: 

Pre-ex is not waived for members who re-enroll to avoid the higher premium cost of their current supplement plan. A new Emerge number must be assigned so that pre-ex will apply to the new record.

Pre-ex is not waived for Corporate members who switch to a Retail plan. A new Emerge number must be assigned so that pre-ex will apply to the new record.

Pre-ex is not waived for members who have a break in coverage unless premium is paid up to avoid the break. A new Emerge number must be assigned so that pre-ex will apply to the new record.

Pre-ex is not waived when required documentation is not provided to us.

USBA Pre-Ex Flag: 

USBA insureds have a “pre-existing flag” on their records in InsPro. This flag tells us whether or not pre-ex will apply.

• YES means there will be a pre-ex limit.
• NO means that it has been waived.

This flag only applies to USBA. This flag only applies to InsPro records created on/after April 1, 2015. Records created prior to April 1, 2015, all say “N” by default, which is not correct as most of these insureds did have a pre-ex waiting period.)

See records with client ID 0002241 to view examples.