Definition: A pre-existing condition is an injury or illness for which you are treated or diagnosed within the 90-day period immediately preceding the earlier of 1) the effective date of your coverage under the plan or 2) any applicable waiting period. Pregnancy is not limited as a pre-existing condition. Genetic information is not considered a pre-existing condition in the absence of treatment or diagnosis related to that information.

Who does this limit apply to?
Any person newly added to a PISD medical plan is subject to the pre-existing condition limitation described below. If you currently have coverage under a PISD medical or alternate plan and are simply switching plans, then a new pre-existing condition limitation will not be applied to you. Also, there is no pre-existing condition limitation applied to children whose coverage begins on the date of birth or date of placement for adoption.

Summary of Limitation

How does the PISD plan limit coverage for pre-existing conditions?

If you enroll in a PISD medical plan, the plan will not cover any pre-existing conditions for 6 months. This 6-month period may be eliminated or reduced if you had "creditable coverage" prior to becoming covered by the PISD plan.

How does prior creditable coverage reduce the limitation period? The plan's limit on coverage for pre-existing conditions will be reduced by any creditable coverage that you had under another plan within the 12 months prior to becoming covered by the PISD plan. Creditable coverage includes most types of comprehensive health coverage, including coverage under a group or individual health plan, Medicare, Medicaid, TRICARE, and SCHIP.

Are there time limits for acceptable creditable coverage? Any creditable coverage you had within the 12 months before your PISD coverage begins will reduce the time period for limited coverage. However, if you had continuous creditable coverage for a total of 12 months or more, then that creditable coverage must have ended no more than 63 days before your PISD coverage begins (or before your waiting period as a new employee begins).

How do I notify the PISD plan about my creditable coverage? Your prior health plan should have sent you a “Certificate of Creditable Coverage” when your coverage with them ended. If not, you can request one from them. Those certificates will be required as proof of creditable coverage, so you should keep them for your records. When you submit a claim to the PISD medical plan for a pre-existing condition, you may include your certificates at that time. If no certificates are included with the claim, then you will receive a letter requesting the information. Once your certificates are received, the time period for your pre-existing condition limitation will be recalculated.

For complete information, please review the Plan document.