Florida Look Back Period for Preexisting Conditions - Need Confirmation

[Ron00]

I was hoping some knowledgeable people here could help clear up some confusion I have about Preexisting conditions as they relate to an Individual health insurance plan.

It's my understanding, that in Florida, state laws state that there is a 24 month Look Back Period in which potential carriers can look at any doctor visits/meds that might be considered a preexisting condition http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0600-0699/0627/Sections/0627.6045.html

Am I interpreting this correctly? For example, I've seen a doctor for allergy problems and back pain, but it's been over two years since I last sought a medical opinion or treatment, so are these issues that can no longer be subject to a medical ryder or grounds for a decline? Can they put a medical ryder on something older than 24 months?

I have an Aetna application that asks for any conditions going back 10 years. Why are they allowed to ask for 10 years of preexisting conditions if state law says they can only look back 2 years? What am I missing here?

 

[timamr]

If it were me, I'd simply answer the questions as they asked on the application. Can't go wrong there!

 

[Ron00]

If it were me, I'd simply answer the questions as they asked on the application. Can't go wrong there!

That doesn't answer my question, I'm looking for clarifications of pre-existing conditions as they pertain to Florida. I'm not trying to get away with something. Why bother replying?

 

[atlasagent]

It is my understanding that 2 years is the rule, but... with many pre-existing conditons the would-be customer may still consult a doctor from time-to-time regarding the conditon, i.e., following up with an oncologist once a year following a cancer surgery. This follow up, even if the doctor gives an "all clear" amount to medical treatment / consulation which re-sets the waiting period all over again. Even though the event may have occurred more than 2 years back, ongoing monitoring is considered active treatment for the disorder, therefore a denial. However... this varies greatly from one carrier to another. Hope this helps.

 

[Yagents]

That doesn't answer my question, I'm looking for clarifications of pre-existing conditions as they pertain to Florida. I'm not trying to get away with something. Why bother replying?

Regardless of what law you read, here is how it applies at each company in the real world, as each treat it differently.

First, all applications ask for the last 5 or 10 yrs of medical history.
Next, having creditable coverage makes a difference.
Lastly, each company approaches it differently:

1. Aetna and Cigna - if you have creditable coverage, they don't rider/exclude medical conditions, and the pre-ex waiting period is waived, if approved, and probably rated up. If NO CCC, all pre-ex treatment within last 1-2 years, will not be covered for the first 11-12 mo, even with approval and rate up.

2. Goldenrule/Humana/Assurant - CCC doesn't matter except for pref/standard pricing. Each of these companies can rider a condition indefinitely. If they don't rider/exclude upfront, then they are assuming the risk and covering the pre-ex. Each have waiting periods built in for certain conditions.

Don't do BCBS FL. Above not applicable to children. My E&O is not covering this, make your own calls once you narrow down company/plan.

 

[leevena]

I do not work the individual market in FL, so I am looking for others to confirm or deny.

More than likely the questions have to do with how they rate the plan. Since this is an individual plan carriers will use a "debit/credit" underwriting methodology. You answer the question and the rate goes up/down depending on the answer. For example, if you are age 30, male, you may start out with a $200 rate. If you are 5'5" and 250 lbs the rate now goes up to reflect the risk. If you live in a low-cost area, the zip code answer will reduce your cost. And so on.

Hope this helps.

 

[Yagents]

Not having prior coverage is starting to cost people in this biz:


Upcoming Golden Rule, UnitedHealthOneSM Updates

In an effort to keep you informed and provide you with advance notice regarding Golden Rule business, this message is to notify you of an update to our rate class definitions.

As of April 20, 2012, our rating classes will be updated to Preferred, Standard 1 and Standard 2, along with the following definitions of each:

• Preferred:
  • Applicant falls within our preferred Height and Weight Build Chart and has been covered by health insurance within the past 63 days.

• Standard 1:
  • Applicant falls within our Standard 1 Height and Weight Build Chart and has been covered by health insurance within the past 63 days. OR
  • Applicant is within the preferred build class, but has had no prior coverage

• Standard 2:
  • Applicant falls within our Standard 1 Height and Weight Build Chart, but has no recent prior health coverage. OR
  • Applicant falls within our Standard 2 Height and Weight Build Chart (regardless of prior coverage)

Applications received on or after April 20, will have the above health rate class definitions applied in most cases.

Updated health applications with these updates will be available on E-Store beginning Friday, April 20th.

Please note: If you have clients who have not yet completed their applications, please have them do so before April 20th. If applicants return to complete their applications on or after April 20, they will be moved to the appropriate rating class based on the above updated criteria.

If you have any questions, please contact our Broker Service Center at (800) 474-4467. Thank you for your business.

 

[IndividualHealthGuy]

I was hoping some knowledgeable people here could help clear up some confusion I have about Preexisting conditions as they relate to an Individual health insurance plan.

It's my understanding, that in Florida, state laws state that there is a 24 month Look Back Period in which potential carriers can look at any doctor visits/meds that might be considered a preexisting condition Statutes & Constitution :View Statutes : Online Sunshine

Am I interpreting this correctly? For example, I've seen a doctor for allergy problems and back pain, but it's been over two years since I last sought a medical opinion or treatment, so are these issues that can no longer be subject to a medical ryder or grounds for a decline? Can they put a medical ryder on something older than 24 months?

I have an Aetna application that asks for any conditions going back 10 years. Why are they allowed to ask for 10 years of preexisting conditions if state law says they can only look back 2 years? What am I missing here?

There are two different things in play here. The 2 years is the look back period for pre-existing conditions that will affect claims payments. The 5 or 10 years asked for on the app are used when underwriting and rating the policy.

 

[Ann H]

I was hoping some knowledgeable people here could help clear up some confusion I have about Preexisting conditions as they relate to an Individual health insurance plan.

It's my understanding, that in Florida, state laws state that there is a 24 month Look Back Period in which potential carriers can look at any doctor visits/meds that might be considered a preexisting condition F.S. 627.6045

Am I interpreting this correctly? For example, I've seen a doctor for allergy problems and back pain, but it's been over two years since I last sought a medical opinion or treatment, so are these issues that can no longer be subject to a medical ryder or grounds for a decline? Can they put a medical ryder on something older than 24 months?

I have an Aetna application that asks for any conditions going back 10 years. Why are they allowed to ask for 10 years of preexisting conditions if state law says they can only look back 2 years? What am I missing here?

There are two distinct issues at play here. The first is UNDERWRITING, and the second is WAITING PERIOD FOR PRE-EXISTING CONDITIONS.

For Underwriting, the carrier may look back more than 2 years, and ask health questions to assess the risk and apply a rate. Some carriers can also apply exclusion riders (waivers) for certain conditions.

Once underwriting is completed and the insurer has approved your application, applied a rate and/or any special riders, then the pre-existing condition clause applies. The pre-existing condition waiting period is what you are referring to when you said that your state restricts it to a 2 year look-back period. Some insurers apply a waiting period for pre-existing conditions (even if they approved an application that disclosed those conditions). Some insurers waive the waiting period if you had a CCC (certificate of creditable coverage, proving that you had prior insurance without a lapse of 63 days or more in the last 18 months). Other insurers have no waiting period for conditions that are fully disclosed on the application. In ALL cases the exclusion rider (waiver) and any exclusions listed in the policy are separate and distinct from the pre-existing condition clause.

It appears to me that you simply misunderstood the distinction between UNDERWRITING's ability to ask health questions for many years in arrears, and a pre-ex waiting period that may be limited to 2 years. The other agents on this post have posted accurate and very detailed answers about the pre-ex clauses in the Florida market. I'm not a Florida agent by the way.
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There are two different things in play here. The 2 years is the look back period for pre-existing conditions that will affect claims payments. The 5 or 10 years asked for on the app are used when underwriting and rating the policy.

Sorry, IndividualHealthGuy, I was writing my post when you posted yours and I didn't realize we were giving the same answer!

 

[IndividualHealthGuy]

It's ok. I think he has the answer he needed now.