# Preg Preex in NJ



## MEDASSURE (Apr 26, 2011)

I have searched the web high and low and keep finding differenct answers:  I have a pregnancy patient, due in about 2 months. She no longer has coverage through her old insurance and just gave us a BCBS EPO card.  This is not through an employer or group, she purchased this insurance on her own.  

BCBS states her pregnancy is preex and will not be covered.  Everything I read seems to state that per HIPAA pregnancy can NEVER be preexisting.  

Please help. I have also left several messages for BCBS legal dept as their "supervisors" just repeat the same thing to me.."pregnancy is preexisting and will not be covered.." My doctor keeps telling me absolutely not and they "must pay", otherwise, I am not doing my job very well...

Any help/insight would be appreciated.

Kim Jawidzik, CPC
MedAssure, LLC
Billing & Consulting


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## btadlock1 (Apr 26, 2011)

MEDASSURE said:


> I have searched the web high and low and keep finding differenct answers:  I have a pregnancy patient, due in about 2 months. She no longer has coverage through her old insurance and just gave us a BCBS EPO card.  This is not through an employer or group, she purchased this insurance on her own.
> 
> BCBS states her pregnancy is preex and will not be covered.  Everything I read seems to state that per HIPAA pregnancy can NEVER be preexisting.
> 
> ...



It sounds like you got an uneducated-guesser on the phone. That couldn't be any more against the law. Call them back and quote them from this: http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html
"HIPAA prohibits plans from applying a preexisting condition exclusion to pregnancy, genetic information, and certain children....

Q:Are there illnesses or injuries that cannot be subject to a preexisting condition exclusion?
A:Yes, as follows: 

Pregnancy, even if the woman had no prior coverage before enrolling in her current employer's plan..... "

Tell them you'll file a complaint with the Office of Civil Rights, and I bet they change their tune. If they don't, then file the complaint (Go here: http://www.hhs.gov/ocr/civilrights/complaints/index.html). They're wrong - there's no two ways about it. 

The only reason you should see pregnancy coverage denied, is if it's a dependent child that's pregnant, and the plan documents state that dependent pregnancy care is not a covered benefit.


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## btadlock1 (Apr 26, 2011)

*Forgot about individual plans*

They're not subject to HIPAA, so you'd have to defer to your state department of insurance for those. See: http://www.health-insurance.org/pregnancy

If it's a group plan (especially employer-based), then they have to cover it under HIPAA. Can't wait 'til 2014 when this all goes away for good...pre-existing is a nightmare.


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## btadlock1 (Apr 26, 2011)

*Found one more thing....*

This was bugging me - can you tell?

http://lis.njleg.state.nj.us/cgi-bin/om_isapi.dll?clientID=372956206&Depth=2&depth=2&expandheadings=on&headingswithhits=on&hitsperheading=on&infobase=statutes.nfo&record={6E89}&softpage=Doc_Frame_PG42
(Who the law applies to)
"a.  Any insurance company, domestic, alien or foreign, now or hereafter organized which in addition to doing the business of health insurance as defined in section 17B:17-4, is licensed to make, or shall hereafter become licensed to make, kinds of insurance other than those defined hereinafter in this chapter, shall be subject only to the hereinafter enumerated provisions of  this Code but only in connection with such health insurance business:

     (1) All the provisions of the following chapters:

      Chapters 22, 26, 29, 34 and 35.

      (2) All the provisions of the following sections:

      17B:17-1, 17B:17-2, 17B:17-4, and 17B:17-6 through 17B:17-14; 17B:18-1, 17B:18-35 through 17B:18-40, 17B:18-63, 17B:18-66;  17B:19-5; 17B:24-1 through 17B:24-5, 17B:24-8 and 17B:24-9;

      (3) All of the provisions of the following articles of the designated chapter.

      Articles 2 and 3 of Chapter 27.

    b.  The provisions of the following chapters and sections shall not be applicable to those insurance companies described in subsection  "a" above:

     (1) Chapters 21, 23, 30 and 33.

      (2) 17B:18-41, 17B:18-42, 17B:18-47, 17B:18-56, 17B:18-57, 17B:18-58, 17B:18-64, 17B:18-65 and 17B:19-1.

    All such companies will remain subject to subtitle 3 of Title 17 except as above provided.

    c.  Any insurer now licensed under R.S. 17:17-1, d. solely to do the business of health insurance shall be subject to every provision of this Code as a health insurer.

    d.  An insurer may be organized under the provisions of section 17B:18-4 to  do the business of health insurance as defined in section 17B:17-4 and in addition kinds of insurance other than those kinds defined in this chapter, and  in such case, it shall have all the obligations, powers and privileges of a  health insurer organized under this Code and shall to the extent not inconsistent herewith be subject to all the provisions of Subtitle 3 of Title 17.

    e.  Except as otherwise specifically provided no provision of this Code shall apply to:

    (1) Fraternal benefit societies as defined in Part 5A of Subtitle 3 of Title  17.

    (2) Mutual benefit associations as defined in Part 6 of Subtitle 3 of Title  17.

    (3) Hospital and medical service corporations as defined in Part 9 of Subtitle 3 of Title 17.

     L.1971, c. 144, s. 17B:17-1.

 17B:17-2.  Insurer defined
      "Insurer"  includes every person engaged as indemnitor or contractor in the  business of life insurance, health insurance or of annuity.

     L.1971, c. 144, s. 17B:17-2."


and...

(The state law)
http://law.onecle.com/new-jersey/17b-insurance/27a-22.html
New Jersey Statutes - Title 17B Insurance - 17B:27A-22 Preexisting condition provisions
"17B:27A-22. Preexisting condition provisions

     6. a. No health benefits plan subject to this act shall include any provision excluding coverage for a preexisting condition regardless of the cause of the condition, provided that a preexisting condition provision may apply to a late enrollee or to any group of two to five persons if such provision excludes coverage for a period of no more than 180 days following the effective date of coverage of such enrollee, and relates only to conditions, whether physical or mental, manifesting themselves during the six months immediately preceding the enrollment date of such enrollee and for which medical advice, diagnosis, care, or treatment was recommended or received during the six months immediately preceding the effective date of coverage; provided that, if 10 or more late enrollees request enrollment during any 30-day enrollment period, then no preexisting condition provision shall apply to any such enrollee.

     b. In determining whether a preexisting condition provision applies to an eligible employee or dependent, all health benefits plans shall credit the time that person was covered under creditable coverage if the creditable coverage was continuous to a date not more than 90 days prior to the effective date of the new coverage, exclusive of any applicable waiting period under such plan. A carrier shall provide credit pursuant to this provision in one of the following methods:

     (1) A carrier shall count a period of creditable coverage without regard to the specific benefits covered during the period; or

     (2) A carrier shall count a period of creditable coverage based on coverage of benefits within each of several classes or categories of benefits specified in federal regulation rather than the method provided in paragraph (1) of this subsection. This election shall be made on a uniform basis for all covered persons. Under this election, a carrier shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within that class or category. A carrier which elects to provide credit pursuant to this provision shall comply with all federal notice requirements.

     c. A health benefits plan shall not impose a preexisting condition exclusion for the following:

     (1) A newborn child who, as of the last date of the 30-day period beginning with the date of birth, is covered under creditable coverage;

     (2) A child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This provision shall not apply to coverage before the date of the adoption or placement for adoption; or

     (3) Pregnancy as a preexisting condition.

     L.1992,c.162,s.6; amended 1995, c.298, s.2; 1997, c.146, s.9."

They're awfully brazen to have it on their website, if they haven't found a way to side-step the laws. They've found a loophole somewhere - I'd request full written disclosure from the legal department. Good luck.


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## MEDASSURE (Apr 26, 2011)

Thanks Brandi! Looks like you were doing as much research as I did.  I kept finding that under HIPAA ALL pregnancies are considered non preexisting (except for the dependent of an insured) BUT... then she MAY NOT fall under HIPAA due to individual coverage, lapse in coverage, etc. I will try the state ins web site again, BUT still very confusing and I can't seem to get a concrete answer anywhere.   I've have already been denied one delivery for these same reason about 2 years ago, don't want to have to go thru this again.  Like I said I've also left messages for the BCBS legal dept, but don't want to look like an idiot if I am wrong.. but I will FIGHT TO THE DEATH if I am right.. lol

Thanks for your input.  Looks like more research for me!

Kimberly Jawidzik, CPC
MedAssure, LLC


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## btadlock1 (Apr 26, 2011)

MEDASSURE said:


> Thanks Brandi! Looks like you were doing as much research as I did.  I kept finding that under HIPAA ALL pregnancies are considered non preexisting (except for the dependent of an insured) BUT... then she MAY NOT fall under HIPAA due to individual coverage, lapse in coverage, etc. I will try the state ins web site again, BUT still very confusing and I can't seem to get a concrete answer anywhere.   I've have already been denied one delivery for these same reason about 2 years ago, don't want to have to go thru this again.  Like I said I've also left messages for the BCBS legal dept, but don't want to look like an idiot if I am wrong.. but I will FIGHT TO THE DEATH if I am right.. lol
> 
> Thanks for your input.  Looks like more research for me!
> 
> ...



Hey, now - the first rule of follow-up, is that it doesn't matter what the people on the payer side think of your intellect. 1. Most of the time, they don't know who you are, and will never talk to you again. 2. With some payers (especially those that outsource call centers), the people in their provider services department have barely been working there the same amount of time (or less) as your most recent aging claims have been in existence; many won't be last as long as it takes for your claim review to complete. 3. You can usually get a LOT further by playing dumb - sometimes it's the only way to get someone to realize that what they're saying doesn't make sense. 4. It's their job to be clear, direct, and to help you understand their actions. If they can't do that effectively, that's their problem, not yours. 

I do understand the drive to be right, though. Try calling *provider** relations *(not provider services) and telling them what you're being told - approach it as though they are the only ones knowledgable enough, and therefore capable, to help solve your problem. If you sound confused, and like you're begging for help understanding the situation, many times, you can actually get claims sent back that you wouldnt have been able to with an authoritative approach. Happy appeals!


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