515 Insurance Coverage (No Creditable Coverage)

 

 

 

Revised 06/08/2015

 

Policy

 

People who have creditable health insurance coverage do not qualify for:

·         Breast and Cervical Cancer Treatment Program (BCCTP);

·         KidsCare.

 

Exception:

A woman who has creditable coverage may qualify for BCCTP if:

·         The insurance company will not cover the breast or cervical cancer treatment, because it is a pre-existing condition;

·         She has exhausted her lifetime limit for all benefits under the insurance.  This includes coverage for breast or cervical cancer treatment; or

·         She is in a mandatory waiting period before she can get medical services through the policy.  BCCTP eligibility ends once the waiting period is over

 

Definitions

 

Term

Definition

Creditable Coverage

Health insurance coverage as defined under the Health Insurance Portability and Accountability Act (HIPAA).

NOTE      Eligibility for services through Indian Health Service (IHS) or a tribal organization is not considered creditable coverage for BCCTP.

Examples of creditable coverage include:

·         Medicare;

·         Group health plans including Qualified Health Plans;

·         Health insurance coverage through a hospital or medical service policy, certificate or plan contract; or

·         Armed forces insurance (i.e., Tricare).

Non-Creditable Coverage

The following types of policies are considered non-creditable coverage:

·         Coverage only for accidents (including accidental death and dismemberment);

·         Liability insurance, including general liability and automobile liability insurance;

·         Free medical clinics at a work site;

·         Benefits with limited scope such as dental benefits, vision benefits or long term care benefits;

·         Coverage for a specific disease or illness (including cancer policies);

·         Insurance that pays a set amount a day when the person is hospitalized or unable to work.

 

Proof

Accept the customer’s statement on the application that he or she has no health insurance unless there is evidence to the contrary.

Evidence to the contrary may include but is not limited to:

·         Social Security records showing the person has Medicare;

·         Pay stubs that show deductions for group health insurance.

·         The customer reported insurance coverage on a recent application.

·         Health insurance listed in AHCCCS’ PMMIS database on the RP 155 screen.

NOTE  Health insurance on this screen may be out of date.  Always call the insurance carrier to confirm the coverage is current and if there are any limits.

 

Proof of whether coverage is creditable and what is covers includes:

·         A telephone call with the insurance company to confirm the coverage type and any limitations;

·         A copy of the insurance policy.

Legal Authority

 

Program

Legal Authorities

Breast and Cervical Cancer Treatment Program (BCCTP)

42 USC 1396(a)(10)(A)(ii)(XVIII)

ARS 36-2901.05

AAC R9-22-2003

KidsCare

42 USC 1397jj(b)(1)(C)

42 CFR 457.310(b)(2)(ii)

ARS 36-2983(G)(2)

AAC R9-31-303(6)