Eligibility and Plan Information

CeltiCare Health Plans

Eligibility Requirements--To qualify for CeltiCare coverage, primary applicant must be six months or over and under 64 1/2 years of age and must not be covered under any other health insurance plan.  Insured must be a United States citizen or a foreign resident who has been living in the United States for at least two years under a permanent visa.  Dependents must be 6 weeks or older.

Underwriting--Your CeltiCare application is individually underwritten based on the health history of you and your covered dependents.   To effectively underwrite your application, Celtic must obtain as much medical information about you as possible.  This is accomplished through the use of health questions on the application form and, in some instances, a follow-up medical questionnaire and/or telephone verification of information.  In addition, Celtic may request medical records as necessary.

Credit for Prior Deductibles--If you choose to replace current insurance coverage with the CeltiCare Health Plan, you will receive credit for satisfying any portion of the previous carrier's deductible in the same calendar year.  Copies of EOBs (Explanation of Benefits) are required for proof of deductible.

Creditable Coverage--Time spent under the CeltiCare Health Plan may or may not count towards "creditable coverage" as defined in the Health Insurance Portability and Accountability Act, Public Law 104-191.  Your individual circumstances, as well as state and federal law, will determine how much, if any, of your coverage under the CeltiCare Health Plan is creditable coverage.  If you intend to terminate your health insurance coverage with Celtic Insurance Company and replace it with other health insurance coverage, you should check with the new insurance company to find out if you have to show proof of insurability and meet a new pre-existing condition waiting period.  

Pre-Existing Conditions--A pre-existing condition is a sickness or bodily injury for which an insured person received a diagnosis, medical advice, consultation or treatment during the 12 months prior to the effective date, or for which an insured person had symptoms 12 months before the effective date which would cause an ordinarily prudent person to seek medical care or treatment.

Celtic will provide full coverage of pre-existing medical conditions if certain specific guidelines are met.  The applicant must fully disclose all pre-existing medical conditions on the application.  Then, if they pass our underwriting guidelines, on a standard basis, we'll provide full coverage.  Benefits are not paid for an insured person's undisclosed pre-existing condition until coverage has been in force 12 months from the effective date provided coverage was issued on a standard basis.

Term Life Insurance--If available in your state, you may elect the Term Life Insurance option, which pays a benefit to the beneficiary if the primary insured person dies.  The maximum benefit amount is $25,000 for individuals ages 18-64 1/2 and $10,000 for individuals ages 6 months-17 years.

When Coverage Begins and Ends--Your effective date will appear on the schedule page of your Certificate Booklet or Policy, provided that you mail in your premium payment with your application and are accepted for coverage.

Coverage ends when:

• the lifetime maximum benefit has been paid;
• you fail to make the required premium payments;
• you cease to be an eligible dependent;
• you begin living outside the United States;
• the Master Policy is terminated.  Celtic may cancel the Policy on the first of any month by giving 60 days prior written notice.

Celtic's Health Care Certification Program--Health Care Certification is a benefit which is automatically included in the CeltiCare Health Plan.  The Health Care Certification Program promotes high-quality medical care and can help you better understand and evaluate your treatment options. 

How does it work?--You need to contact the Celtic Health Care Certification Program at 1-800-477-7870 to certify medical treatment.  The review team is made up of medical advisors with backgrounds in the medical, surgical, and psychiatric fields.  If you have concerns about your proposed treatment, they can help you develop appropriate questions to ask your physician.  The medical advisor may also discuss possible alternatives with your doctor if there are any questions regarding the necessity of your treatment.  Celtic-recommended second surgical opinions are always paid at 100%.  Also, in event of a non-certification, there is an appeal process available.

Remember, the final decision for medical treatment is always the right and responsibility of you and your doctor.

What if I don't notify Celtic before treatment?--For all plans, non-notification results in an exclusion from eligible expenses of 20% of all charges related to the treatment, if you did not notify the Celtic Health Care Certification Program before treatment.

What if my treatment is considered not medically acceptable and/or not medically necessary?--A "Notice of Non-Certification" is issued to you and your doctor. If you decide to receive the non-certified treatment, no benefits are paid. 

Acceptance into the Trust--Individuals meeting Celtic's underwriting guidelines are accepted into the Celtic Health Plan Trust, which acts as the policyholder of the CeltiCare Health Plan.  The Trust is located in Illinois and complies with applicable Illinois laws.