Pre-existing Condition Clauses

[PeteNYNJ]

Hello All

I have some questions about a confusing situation I find myself in as of late.  I started a new job on August 2nd.  The next day my Cobra ran out.  I will not be offered insurance from my company until Oct 1 with is within the allotted time period that my new insurance company will not be able to apply any preexisting condition clauses.

Here is where it gets tricky - I don't get full access to benefits until 6 months after I start the job.  The insurance they offer in Oct is Essential Care, which doesn't cover any scripts for antivirals and such.  I will only be using this for blood work and routine medical issues.  I will be getting my drugs through ADAP so no worries there.

When I apply for my "real" insurance, I think it is Cigna, will I be covered fully even though I didn't use the Essential Care insurance I am carrying up until that point for anything particularly HIV related?

I know it is kinda confusing so if you need further clarification ask away, otherwise would love to hear your 2 cents on the issue.

Pete

[Joe K]

Pete,

How many employees does the company have? Generally, when you join a group plan, you are fully accepted, even if actual benefits vary by length of service. Some people refer to it as an "open enrollment" and since your Cobra excludes a pre-existing clause, you should be fine. If you have any questions, talk with your Human Resources about your concerns and you don't have to share any personal information to get the answers you need.

[PeteNYNJ]

My employer has 10K plus employees.  I know they will not deny me insurance, but they (insurance company) can limit the services they pay for if they determine it a preexisting condition.

Case in point, I went from one big employer to another with no gap at all in insurance coverage and my first bloodwork/doctor check up, I was sent a letter having to prove I carried insurance before or they would not pay for that service.

[Inchlingblue]

My employer has 10K plus employees.  I know they will not deny me insurance, but they (insurance company) can limit the services they pay for if they determine it a preexisting condition.

Case in point, I went from one big employer to another with no gap at all in insurance coverage and my first bloodwork/doctor check up, I was sent a letter having to prove I carried insurance before or they would not pay for that service.

Madbrain is the resident expert on this subject but the way I understand it is you are allowed a maximum of 63 days without coverage before they are able to apply pre-existing conditions. They are then able to apply pre-existing conditions for a length of time equal to the time you were without insurance.

Can I reduce or eliminate the maximum preexisting condition exclusion period?

Yes, if you can show "creditable coverage." Most health coverage can be used as creditable coverage, including participation in a group health plan, COBRA continuation coverage, Medicare and Medicaid, as well as coverage through an individual health insurance policy. However, you should try to avoid a significant break in coverage (63 days) if you want to be able to count your previous coverage. If you have a break shorter than 63 days, coverage you had before that break is creditable coverage and can be used to offset a preexisting condition exclusion period. Days spent in a waiting period for coverage cannot be used as credit. But, they also are not counted toward the significant break (63 days) you are trying to avoid.

How do I calculate the length of a preexisting condition exclusion in a new employer’s health plan?

Suppose an employee had coverage for 2 years, followed by a break of 70 days. The employee then resumes coverage for 8 months before moving to a new job, with no time off between jobs. He enrolls in the health plan at the new job as soon as possible.
A preexisting condition exclusion can last 12 months at most, if the person enrolls when first eligible. This employee has 8 months of creditable coverage. His earlier 2 years of health coverage are not creditable because he had a break in coverage that was more than the 63 days allowed under the law. His preexisting condition exclusion will last 4 months after he enrolls in the employer's health plan.
If the same employee had a break in coverage of only 60 days, his story would be different. This would not be a significant break and he could use the earlier 2 years of coverage to completely offset the preexisting condition exclusion period.


There are other helpful Q&A's on the link below. These time periods mentioned (63 days, etc) are a minimum based on Federal HIPAA laws but some states have a more generous allowance.
 
LINK:

http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

[tednlou2]

What things did the health insurance companies claim they would go ahead and enact now instead of when it is mandated?  I know I heard on the news they are claiming they are going to voluntarily enact some things before they are mandated.  Does anyone know what they are and if they are really doing it??

[Assurbanipal]

Pete

Your old (COBRA based insurance company)  should send you a a certificate of creditable coverage.  If they don't, call and ask for it.

Second, ask your employer / HR people to clarify whether the CIGNA plan has any provisions about preexisting conditions (as Joe / Killefoile pointed out, many large employer plans don't) and if it does whether "Essential care" insurance counts.  If you don't feel comfortable asking this much about the details just ask for a copy of the plan SPD (summary plan description)

If the plan that starts in October is creditable coverage (and it is hard to see how it wouldn't be -- although it wouldn't hurt to check) you would basically not be subject to any preexisting condition clauses since the break between your COBRA coverage and the new plan was too short to matter.

PM me if I can help

A