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Blue Cross Blue Sheild: Pre-Existing Condition Exclusions by State (AL, AK, AZ, AR)


It seems that folks are interested in finding out how Blue Cross Blue Shield (BCBC) handles pre existing conditions. The answer varies depending on type of plan’s home state. After doing a little searching for Blue Cross Blue Shield pre-existing conditions and found the following:

Definition of Pre-Existing Condition as Found in the Blue Cross Blue Shield glossary

Pre-existing condition. In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage.”

After finding the general definition that Blue Cross Blue Shield uses to define pre-conditions, I decided to go through each state to see how the individual states handled the exclusion. Keep in mind that there may be variations within the sate because of the different plans available.

If you are trying to find out how each plan handles pre-existing conditions, I strongly recommend that you contact BCBS directly. In the meanwhile, here’s what I’ve found so far (this will take a while since there are so many states):Blue Cross Blue Sheild

Alabama: Blue Cross Blue Shield Pre-Existing Condition Exclusion:

There is a 365-day pre-existing exclusion period before the plan pays benefits for:

  • Pre-existing conditions (condition for which you received medical advice, diagnosis, care or treatment preceding enrollment in the plan);
  • Maternity services; and
  • Certain surgical procedures, including removal of tonsils and adenoids, hysterectomy, joint replacement, surgery to insert tubes into the ears and surgery to treat a birth defect.

Additional treatments may be excluded; please refer to the contract booklet for a complete list. All other eligible medical services will be covered on and after the effective date of your coverage. Because this is not a group plan, periods of prior coverage will not reduce pre-existing and other waiting periods under this plan. However, if you enroll in this plan and then later cancel to enroll in a group plan, you may use the period of coverage under this plan to reduce any pre-existing waiting periods under the new group plan provided there is not a gap in coverage of more than 63 days.”

A Potential Solution to the Alabama Residents:

Check out the Alabama Pre Existing Condition Insurance Plan.  If you’ve been without health insurance for at least six months, are a US citizen and have a pre-existing condition or have been denied coverage because of your condition, you qualify for coverage under the plan.

As with all health insurance plans, make sure to read all of the eligibility requirements.

Blue Cross Blue ShieldAlaska: Premera Blue Cross Blue Shield Pre-Existing Condition Exclusion:

“There is a 12-month waiting period for pre-existing conditions. A pre-existing condition is a medical condition that was diagnosed, or for which care, treatment or advice was received or recommended in the 12 months prior to your effective date on your Premera plan.”
A Possible Solution for Alaska Residents (maybe)?

Alaska offers a health insurance plan for those who are denied coverage as a result of pre-existing conditions. The only problem is that the coverage offered through the Alaska Comprehensive Health Insurance Association is very expensive.
Arizona: Blue Cross Blue Shield Pre-Existing Conditions

Here’s how Arizona’s Blue Cross Blue Shield’s 2010 BlueEssential Plan responds to pre-existing conditions. Keep in mind, however, as with all states, there are several different plans that may contradict the wording below. Read further and you’ll see what I’m talking about.

“AN 11 MONTH WAITING PERIOD FOR PRE-EXISTING CONDITIONS MAY APPLY. A pre-existing condition is defined as a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the six (6) month period immediately preceding the member’s enrollment date. A condition exists when the subscriber had signs or symptoms, whether or not a specific injury,
illness or disease is diagnosed. For purposes of determining a pre-existing condition and pre-existing condition waiting periods, enrollment date means
the member’s effective date of coverage under this benefit plan or the first day of the group’s eligibility waiting period, whichever is earliest.

IMPORTANT: Pregnancy is not considered a pre-existing condition. Credit will be given for periods of prior creditable coverage as long as there was no period of sixty-three (63) days or more (excluding the employer group’s eligibility waiting period) during which a member was not covered under any creditable coverage. Creditable coverage includes the following: coverage provided under a group health plan (insured or self-insured), an individual insurance policy, Medicare, Medicaid, a federal or state public health plan, a health risk benefits pool, TRICARE, the Peace Corps, a Bonafide Association, Indian Health Services, the Federal Employee Health Benefits Plan or the State Children’s Health Insurance Plan. Members have the right to demonstrate to BCBSAZ that they have had prior creditable coverage by providing a Certificate of Creditable Health Coverage or other documentation of such coverage. BCBSAZ can calculate creditable coverage prior to member’s effective date upon request. Please call our Membership Services Department at (602) 864-4456 for additional information.”

Here’s the pre-existing condition wording taken from the 2009 Blue Cross Blue Shield Individual & Family HMO Product booklet which compares Blue Secure and Blue Secure Plus:

“Pre-existing condition waiting period: No waiting period for pre-existing conditions, except routine maternity not covered until 12 months after policy effective date.”

As you can see, the two plans respond to pre-existing conditions differently. In the BlueEssential plan pregnancy is not a pre-existing condition, but in the HMO Products booklet, it excludes routine maternity care for 12 months. This stresses the importance of reviewing the fine print of your plan.

To further muddy the waters, Arizona’s Blue Portfolio PPO Plan Benefit Summary booklet states the following:

“AN 11-MONTH WAITING PERIOD FOR PRE-EXISTING CONDITIONS APPLIES. A pre-existing condition is defined as a condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received during the 12 months before your effective date. Services for pre-existing conditions are not covered until 11 consecutive months after the benefit plan effective date.”

Help for Uninsured Arizona Residents

Prior to the passage of President Obama’s Health Care reform, Arizona residents did not have a health insurance pool to provide coverage for the uninsured. Now, with the passage of the reform in March of 2010, Arizona must create a health insurance pool within 90 days of the passage of the reform. There are, however, a few programs that benefit low income Arizona residents.

Here’s an interesting post regarding health care reform in Arizona.

Blue Cross Blue ShieldArkansas: Blue Cross Blue Shield

Blue Cross Blue Shield Arkansas seems to have a “standard” pre-existing exclusion on their policies but I wasn’t able to find the wording on their PPO or HMO policies. Apparently the wording doesn’t seem to be available online (by the way, in Arkansas children under the age of 19 are not subject to the pre-existing condition exclusion).

I did, however, find this pre-existing condition wording which applies to their Critical Illness Coverage offered through USAble Life as follows:

“The benefits of this policy will not be payable for any loss caused by a pre-existing condition during the first 12 months the policy is in force. After this 12-month period, however, loss due to such conditions will be payable unless specifically excluded from coverage. This 12-month period is measured from the effective date of coverage for each insured person. A pre-existing condition means a specified critical illness which is diagnosed or treated within 12 months prior to the effective date of coverage for each insured person. Conditions which are: (a) fully disclosed to us on the application and (b) not excluded or limited by us are not considered pre-existing conditions.”

I’m not sure if this is their “standard” pre-existing conditoin wording so, I strongly suggest you call your BCBS representative or plan administrator to ask questions about your specific plan.

One thing I did find out is that pregnancy is not considered a pre-existing condition. Here’s the Q&A from their FAQ (1/4/13 update – Q&A mentioned below has since been removed, but the link to the pre-existing limitation page clearly states that pregnancy is excluded from the pre-existing limitation):

Q. My husband’s employer is changing insurance plans next month, and I am 4 months pregnant. Will my pregnancy be covered under his new plan?

A. Yes. Pregnancy does not fall under the pre-existing condition limitations of a group health insurance plan that has maternity coverage. Your pregnancy will be covered from the first day of your husband’s new plan with Arkansas Blue Cross and Blue Shield. Any charges before you became effective with Arkansas Blue Cross and Blue Shield would not be covered.”

Coverages for Arkansas Individuals with Pre-Existing Conditions

Arkansas has a state Comprehensive Health Insurance Pool (CHIP) for individuals who cannot obtain health insurance elsewhere.

BCBS: California, Connecticut & Colorado


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