Hi,

I recently requested a Certificate of Creditable Coverage from my previous insurer and was told that they do not qualify as creditable coverage, hence no certificate. I was under the impression that group health plans qualify as creditable coverage. I was covered for more than 6 months under this group plan. Any ideas on why they wouldn't be creditable? I can find nothing in their literature stating that they aren't. Needless to say, this has severely damaged my current ability to have my preexisting condition covered under any new insurance and I am extremely upset at learning of this.

Any help or insight is GREATLY appreciated.

Interesting, what reason did they give?

Did you send your request in writing, preferably certified?

You mentioned "previous insurer" but one of the only exceptions is if they are self insured. In other words, do they pay the bills out of a pool? They would not be using Blue Cross, Kaiser, etc and still be self insured. That is one scenario where they are not subject to ERISA.

Also is your previous employer a church of religious organization? If not, the insurer would probably be in non compliance.

I wrote an article about prior creditable coverage

Thank you so much for getting back to me.

In a nutshell, here is my story. I was employed by a franchised restaurant for five years. The owners owned 21 other stores, with a minimum of 50 employees per store. So with at least 1000 employees we definitely had group health insurance (though not all employees participated). Last September we were informed that the company was switching insurance providers. If already enrolled our coverage would simply be rolled over, we'd receive new cards in the mail, all that stuff. Shortly thereafter I received a Certificate of Creditable Coverage from the old insurance provider as I expected (I had continuous creditable coverage for at least 18 months). A month ago I resigned to move to a different city to begin a new job with new insurance. Since I had not yet received my Certificate of Creditable Coverage I called the insurance provider (the one we had been rolled over to) and requested it. The woman with whom I spoke said it was not a certificate but she would be happy to email me a letter stating the dates I had coverage. It sounded odd but okay I'll see what she sends me. The letter states: "This plan is not intended to replace or provide Major Medical Insurance and is not creditable coverage under HIPAA. This is not intended to represent a Creditable Coverage Letter."

In a benefits guide for this provider there is an FAQ section. One of the questions reads: "What is HIPAA and does it apply to Limited Benefit Plans?" The answer underneath reads: "HIPAA is the Health Insurance Portability and Accountability Act passed by Congress in 1996. The Privacy Rule of HIPAA provides the first comprehensive federal protection for the privacy of health information. Yes, the Limited Benefit Plan is covered by HIPAA."

I am certainly not an insurance expert, but I took that statement to mean that the plan is covered by HIPAA. When I called them back, the woman stated that that only referred to the privacy clause of HIPAA. I asked her if it stated anywhere in the literature that their plan was not considered Creditable Coverage. She stated that it was (though did not tell me where in the literature). I have since read through all the literature for their plan 3 times and the only reference I have found to Creditable Coverage regards Massachusetts residents only (I reside in Texas).

So I have sent them an email requesting a location within the literature where I may find that this coverage is not Creditable, and I have also asked for an explanation as to why it is not Creditable coverage since I was under the impression that group health plans qualify. I have yet to receive a response.

More than a nutshell, I apologize. I just want to be thorough.

Thank you so much any analysis you can give.

Sounds to me like a lot of double talk. Call the woman up and tell her you will report them to the department of labor unless they send the cert or prior coverage. They are not in compliance.

BloodSick:

Now you mentioned "limited benefit plan." Now that makes sense.

Some benefits, even though they are group form (IE. accident, dental, vision) are considered "limited scope" and not essential part of a medical plan. So they are exempt from the HIPAA and hence the certificate requirements. Were your benefits provided under a separate (or unbundled) insurance from the regular medical insurance?

The question is "how limited are your benefits?"

Were they bundled with a regular medical plan?

I'm not entirely sure if I can accurately answer your question, but will certainly try. My insurance was definitely limited; I've heard it referred to as a minimedical. As far as bundling, I'm not sure. I know that it was presented sort of 'a la carte,' meaning you could enroll in all or some of separate medical, dental, vision, and life.

However, being that this latest provider was the fourth provider I dealt with during my five year tenure with my employer, I didn't have much reason to believe that this insurance would be any different from what I had in the past. All the previous insurers presented their plans in the same way (a la carte), all offered relatively the same types and amounts of limited coverage, and all provided me with Certificates of Creditable Coverage once they were replaced with the newest provider. I never had breaks in coverage and rolling things over to the newest insurance was always a smooth affair.

That is why I am so shocked that this insurance is not treating things the same way. The consequences for me are, unfortunately, extremely bad. I am now unable to have my pre-existing condition covered with my new insurance because obviously I cannot present to them a Certificate of Creditable Coverage to reduce the waiting period. I've gone well over the 63 day lapse in creditable coverage (without my knowledge until a few days ago when I discovered all this). And the kicker is, looking into Obamacare's high risk pool, I can't qualify for that either because I did indeed have some sort of insurance during the previous six months (it just wasn't creditable).

I now have no way to help pay for the bloodwork and chemotherapy that I need to stay alive. And I still have not heard back from the insurance provider on where in the literature I could have found this all out so that I could have been more well informed about what kind of insurance I really had and done something to protect myself from the lethal predicament in which I now find myself.

What a mess..

Did you have the separate medical portion of the minimedical options?

Also what we re the circumstances of you losing COBRA? Was it administrator error or was the notice confusing? Don't give up (yet). There may still be some things you could contest.

When I elected coverage, I selected medical & life only, no vision or dental.

As far as COBRA, I have yet to receive anything from them either. My previous employer may not have termed me though on my final date of work (there may have been a week or two lag before I was termed from their system, so that may explain why I have yet to receive anything from COBRA).

Since the start of our dialogue on this forum, I have managed to find a few things online that have shed a bit of light on my situation. Apparently there are two types of limited benefit plans: co-insurance and indemnity-based (I was not aware). From what I have read, I am thinking that all of the insurance I had before this last provider was co-insurance, which is creditable. Indemnity-based is not, even if it is group insurance offered through an employer. I am thinking that this most recent provider is indemnity-based, thereby skirting the minimum creditable requirements.

I have also discovered that the most likely reason for the switch from my previous co-insurance type to the indemnity-based type is the majority of providers offering co-insurance cannot meet the new regulations enacted by the new federal health reform laws. However, indemnity-based is apparently exempt from these new regulations.

So I guess in a sense I have figured out the "why." However, it still doesn't address the fact that this extremely important difference between the two types and the consequences of having one vs. the other was never made clear to me in any of the literature I received when the switch was made. Granted, I am fully aware that it is everyone's responsibility to read the fine print. And I am the type of person that actually does read it. Since being diagnosed, I have taken it upon myself to educate myself as much as possible about insurance so that I don't ever find myself in a bad situation. I have a college degree and I'm pretty good at deciphering and comprehending the gist of most legal documents.

So if after three complete readings of the literature I still can't get a sense that this insurance isn't creditable, how does a company or an industry expect the average person to truly understand the product for which they are paying, and in cases such as mine, relying on to keep them alive?

I have come to the conclusion that the health reform laws are what caused my insurance to change from co-insurance to an indemnity-based insurance without my knowledge, essentially robbing me of creditable coverage. Because of my lapse, I am now one of those "uninsurable Americans with a pre-existing condition" for whom these reform laws were supposedly designed to help. But because I did indeed have some form of insurance within the past 6 months (just not the right kind), I can't even be eligible for the federal high-risk pool that was created to give immediate coverage to those with pre-existing conditions, such as myself.

I'm not even a political person really, but that's just how I see things happening for me. I am guessing COBRA is my only option now. And unfortunately, I can't really afford it.

I was just reading myself:

Fixed-indemnity-style limited medical plans that do not issue creditable coverage letters or represent themselves as a “true group health insurance plan” are exempt from the new regulations because they are considered supplemental.

Get a summary plan description from your previous employer. Make sure it's an indemnity style limited benefit plan.

Just a quick update-- still no reply from the insurance company regarding my query on where in the literature it states the coverage is not creditable. I will send a second request.

Out of curiosity, is the difference between co-insurance based and indemnity based insurance (that being that one is creditable and one is not) supposed to be common knowledge for a consumer of insurance such as myself? I have yet to find anyone who is aware of this difference.

Thank you again for all the help and insight you are giving me.