Sunday, October 31, 2010

Blue Cross Blue Sheild: Pre-Existing Condition Exclusions by State (CA, CT, CO)

I realized that having one post with the Blue Cross Blue Shield pre-existing condition exclusions for all 50 states would be exceptionally long so I decided to break it up and spread it over several posts. This page will contain the pre-existing condition wording for California, Colorado and Connecticut.

California Blue Cross Blue ShieldCalifornia: Blue Shield PPO and HMO

When it comes to pre-existing conditions California's Blue Shield PPO plans provide the following wording:

'For our Blue Shield PPO plans, benefits will not be provided for pre-existing conditions in the first six months of coverage. This exclusion may be waived if you have prior creditable coverage. You may have prior creditable coverage if your previous health plan covered the services in question and your application for Blue Shield coverage was received by us within 63 days of terminating your previous plan coverage.'

The FAQ is silent regarding a pre-existing condition exclusion on their HMO policies. However, a little further down the page, they mention pregnancy as a "waivered" condition. Because it is a waivered condition, pregnancy and maternity services are not covered for the first six months of coverage. Here's the exact wording:

'With Access+ Value HMOSM and Access+ HMO®, pregnancy is a waivered condition. Therefore, benefits for pregnancy and maternity services are not covered for the six-month period from the effective date of coverage, with the exception of services required to treat involuntary complications of pregnancy. However, if you have prior creditable coverage and you apply for coverage within 63 days after termination of prior coverage, Blue Shield will credit the length of time you were covered on your previous health plan toward the six-month period. Please note that for Vital Shield, Vital Shield Plus, Active StartSM, EssentialSM, BalanceSM and Shield Savings plans, pregnancy and maternity benefits are not covered."

I did a little more investigating and took a look at the two HMOs (Access+ Value and Access+) product brochure and nowhere in the brochure did it mention anything about pre-existing conditions.

Since they are silent regarding pre-existing conditions, am I to assume that they are covered? Well, I don't think that's a safe assumption. If you are about to switch plans and are considering one of California's Blue Shield HMO plans, speak to the plan administrator or someone from Blue Shield to make sure your pre-existing condition is covered. It's hard to tell from their online information.

Update: According to the Department of Labor an HMO cannot impose a pre-existing condition exclusion. What they do have are 'affiliation periods' which is the period of time between enrollment and the time coverage goes into effect. The affiliation period cannot last longer than 2 months (3 months for late enrollees) and a pre-existing condition exclusion cannot be imposed.

Colorado Blue Cross Blue ShieldColorado: Anthem Blue Cross and Blue Shield

As with all BCBS plans, you must find out how your particular plan responds to pre-existing conditions. After looking at a few of Anthem Blue Cross Blue Shield PPO plan summaries, the pre-existing condition exclusion can run anywhere from 6 months to 18 months (18 months is the maximum allowable by law for late enrollees. The pre-existing condition exclusion for all other participants may not exceed 12 months).

Here's how Colorado's Anthem BCBS defines a pre-existing condition:

'A pre-existing condition is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the last six months immediately preceding the date of enrollment or, if earlier, the first day of the waiting period; except that pre-existing condition exclusions may not be imposed on a newly adopted child, a child placed for adoption, a newborn, other special enrollees, or for pregnancy.'

A Possible Solution

If you are a Colorado resident with an uncovered pre-existing condition, check out CoverColorado ( They provide coverage to individuals who have been denied coverage because of a pre-existing condition (or have exhausted COBRA benefits).