Pre-existing Conditions in the US

Darkewolfe

So, I know all my problems will (theoretically) be solved once universal healthcare kicks in, but I've got a few years to survive yet. In the mean time...

I've got great health coverage at my current job. My girlfriend has great coverage at her job. She's looking to change jobs, though, to a smaller company that only subsidizes the cost of buying individual plans. She has sarcoidosis, in remission, which is a pretty rare disease. So far it's only popped up twice, each time putting her briefly in the hospital and then going away. Hopefully it's gone forever. Anyway, it's there and documented. She's going in to salary negotiations, and we want to factor the possibility that her health insurance will be more expensive, or that she may be denied for a pre-existing condition. I don't know where to start figuring that out, can anyone provide advice?

Additionally, I'm a cancer survivor. I have a lot of expensive care that still goes into monitoring and scanning, etc. every three months, plus there's always the chance I'll have to go through another round of expensive care if something pops up. Our plan has always been to immediately marry if I lost my health coverage for any reason. How should we take that into account when considering having her find her own insurance, just subsidized by work.

I may not even be asking the right questions on this subject, part of what I need is some info to help me figure out what questions to ask.

Thanks!

Savant

A lot of health insurance law, at least currently, is state based. So you'll have to look into the particular regulations of the state involved where you would live/move to over what sorts of restrictions there are on discrimination based on pre-existing conditions. I think this tends to be a bit less of an issue for group employer based health insurance since rates are set on the group as a whole, pooling together the risks/prices for everyone sharing the plan, as opposed to individual health insurance plans where you are going to have trouble starting up coverage in lots of states. If you are going to have to deal only with individual health plans you are going to want to pay close attention to the rules in your state.

I know some of the common restrictions is that even if you get a policy the insurance company will refuse to pay claims for preexisting conditions for a set period of months when you sign up, until that exclusion expires. I believe this issue mostly comes up if there is a lapse in your health insurance coverage, so you are going to want to be the most careful about what you'll be hit with if you let your health insurance drop.

Also, supposedly the interim high-risk pools are being set up by the Federal health insurance reform currently, so if other options fail you can get coverage through those. Some of those are state based (and are built on already present high risk pools) and some are Federally administered, so again you are going to need to look into the state specific situation.

Phoenix-D

Go into the details of the plan is the best advice here. In GENERAL, as long as you don't have a gap in insurance coverage you don't have to worry about pre-existing stuff, but some plans may have exemptions! Usually along the lines of "if this develops in the first 6 months we're not covering it" type of deals.

Dropping Loads

Darkewolfe wrote: »

So, I know all my problems will (theoretically) be solved once universal healthcare kicks in, but I've got a few years to survive yet. In the mean time...

I've got great health coverage at my current job. My girlfriend has great coverage at her job. She's looking to change jobs, though, to a smaller company that only subsidizes the cost of buying individual plans. She has sarcoidosis, in remission, which is a pretty rare disease. So far it's only popped up twice, each time putting her briefly in the hospital and then going away. Hopefully it's gone forever. Anyway, it's there and documented. She's going in to salary negotiations, and we want to factor the possibility that her health insurance will be more expensive, or that she may be denied for a pre-existing condition. I don't know where to start figuring that out, can anyone provide advice?

Additionally, I'm a cancer survivor. I have a lot of expensive care that still goes into monitoring and scanning, etc. every three months, plus there's always the chance I'll have to go through another round of expensive care if something pops up. Our plan has always been to immediately marry if I lost my health coverage for any reason. How should we take that into account when considering having her find her own insurance, just subsidized by work.

I may not even be asking the right questions on this subject, part of what I need is some info to help me figure out what questions to ask.

Thanks!

Are you moving to the US, or are you already here? Usually it gets covered as long as you don't have a drop in coverage between insurers, although that is something you have to check specifically. If you're moving from another country you're probably in trouble.

That's all the advice I have, but it's really just a cover for saying it's bad ass you're still having a good time and kicking it here with us . It's been awesome playing games and chatting with you.

Darkewolfe

Haha, thanks Brew. Yeah, we're here in the U.S., and I don't expect to have a lapse in coverage. That's my big concern, since she'll be moving to individual coverage rather than group coverage with the new job. The emergency plan has always been to get married early if I was going to have to go uninsured otherwise.

Deebaser

Darkewolfe wrote: »

Haha, thanks Brew. Yeah, we're here in the U.S., and I don't expect to have a lapse in coverage. That's my big concern, since she'll be moving to individual coverage rather than group coverage with the new job. The emergency plan has always been to get married early if I was going to have to go uninsured otherwise.

^ See the red, this is bad news if you have pre-existing conditions. What state (or DC) are you in? Depending on the state regs, you could be uninsurable on an individual policy.

If you give us a location, I'd be happy to look it up for you. I spent far too long in the industry and am familiar with navigating regs.

Cauld

I'm a little confused as well, you said the new company would subsidize her healthcare that sounds like group coverage to me. They could subsidize individual coverage, but that would be no different than simply paying her more (except for tax purposes).

mts

depends on the state and who the insurance provider is. my insurer does not have a pre-existing conditions clause. I think the majority of them do now too. Best bet is to find out who the insurer will be and call and ask

Feral

Cauld wrote: »

I'm a little confused as well, you said the new company would subsidize her healthcare that sounds like group coverage to me. They could subsidize individual coverage, but that would be no different than simply paying her more (except for tax purposes).

This. Most of the time, if a company is offering healthcare, the whole company is on a group plan in which case they're not going to deny you coverage or charge you more due to pre-existing conditions. There could be a waiting period until your pre-existing condition is covered, but only if you went a period of time without coverage. If you go from one group plan to another group plan immediately, you typically don't have to worry about pre-existing conditions at all.

Now if they're telling her "go find individual insurance on your own and we'll reimburse you for the premiums..." well, that's pretty dumb. I have heard of very small companies doing that - we're talking less than 5 employees, because 5 employees is the minimum group size necessary for a lot of group plans. If this is what's happening, it puts you in a bad situation. You're not totally fucked, but depending on a lot of factors (including your state of residence) this could be anywhere from kind of bad to very bad.

Get this clarified because I don't want you to get confused with advice that doesn't apply to your situation.

Darkewolfe

Right, in this case the company is not on a group plan. Each employee buys individual coverage, and the employer just subsidizes it. The company is less than 25 people, and it's cheaper to do it that way and get better coverage than to buy the group policy. We live in Virginia.

EggyToast

Here's more details for you in case you can't find insurance, as well:

http://www.hhs.gov/news/press/2010pres/07/20100701a.html

In 2014 "pre-existing conditions" will be banned so you're either going to have a very tough 3 years or a very easy 3 years, depending on whether the insurance companies you look at try to squeeze profit out of their customers or try to plan for the new 2014 rules in advance.

Deebaser

Alright, here is my understanding of how pre-existing conditions work with individual plans in VA:

Here is the exact clause on pre-existing conditions:

&#167 wrote: »

For individual health insurance coverage, such exclusion relates to a condition that, during a 12-month period immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek diagnosis, care, or treatment, or for which medical advice, diagnosis, care or treatment was recommended or received within 12 months immediately preceding the effective date of coverage;

What this means is that so long as she hasn't sought care for this condition within a year, then it isn't a pre-existing condition.

However, VA isn't a "guarantee issue" state and allows "medical underwriting". This means that they get to ask about every health problem she has ever had and deny her coverage based on that AND if she leaves something out and the insurer finds out later, they can retroactively terminate her.

Another fucked up thing your state allows is "Elimination Riders". If they do offer her insurance, they can permanently exclude her pre-existing condition without calling it a pre-existing condition.

Looking at Statehealthfacts.org and the Virginia Administrative Code, your state is VERY anti-individual policy.

Darkewolfe

Yeah. The last time she had to have care was about a year and a half ago. Neither of us has ever gone through a period of being uninsured. I've had continuous treatment for the past year. I think it's possible she could get a policy with her history, but one of the other concerns is what would happen if I lost my job. If she is able to get an individual policy for herself, we get married and I lose my coverage, what rules govern involving your spouse by expanding your existing, individual plan?

Thanks for the help, by the way.

Deebaser

@Feral - It's actually not terribly uncommon for small businesses to give their employees 'X' to buy their own insurance. It is stupid and lazy, but if you have a youngish healthy workforce in a regulatory shithole of a state, giving them $150 extra a month is a lot less of a hassle than dealing with your health insurance company for all your employees. Tax benefits be damned.

Deebaser

Darkewolfe wrote: »

Yeah. The last time she had to have care was about a year and a half ago. Neither of us has ever gone what rules govern involving your spouse by expanding your existing, individual plan?

No idea. sorry.

For group policies, marriage is a qualifyng event as is 'loss of spousal coverage'. I don't know if that applies to individual policies.

Here are the regs. Chapter 211 is HMO goodness, anything not explicitly prohibited here that would benefit an insurer is allowed. Most of the relevant HIPAA provisions cover group plans so I wouldn't bother tearing through the federal regs.

http://leg1.state.va.us/000/reg/TOC14005.HTM.HTM

Darkewolfe

Deebaser wrote: »

@Feral - It's actually not terribly uncommon for small businesses to give their employees 'X' to buy their own insurance. It is stupid and lazy, but if you have a youngish healthy workforce in a regulatory shithole of a state, giving them $150 extra a month is a lot less of a hassle than dealing with your health insurance company for all your employees. Tax benefits be damned.

Well, that's close. They had group coverage, but the cost of coverage has been skyrocketing lately, as I'm sure you know. Because it's a young, healthy workforce, it ended up being cheaper to pursue individual coverage than group, so the company decided to go that way. Sucks for us, I guess.

Deebaser

It sounds like they may have had an employee or a dependent with health issues "ruining it" for everyone else. Since VA is a regulatory shithole, insurers can charge a small business whatever the fuck they want at renewal as long as they offer renewal.

So if the lady in the next cubicle has a son with acute leukemia, Blue Cross can come back at renewal time with a 9999999% premium increase just to get rid of the 'sickie'.

GODDAMN I FUCKING HATE HEALTH INSURANCE COMPANIES

Darkewolfe

Yeah, I agree with you there. I've paid into the system my whole life as a healthy person, and then one day I decided to get cancer. How dare I ruin the free money train that I was providing my insurance company.

Creidhes

HIPAA regulations do cover conversions to individual plans regardless of pre-existing conditions (assuming prior credible insurance for a certain length of time). She can't be denied health insurance but it may be quite expensive ($1k+ a month). If you were to lose your job, again, HIPAA and COBRA programs would keep you and your spouse/dependants insured for at least 18 months (longer under certain circumstances).


While lack of health insurance isn't a reason to marry, a 3-day vacation to Vegas including license and Elvis themed ceremony can be had for much less than $1k.

Darkewolfe

Creidhes wrote: »

HIPAA regulations do cover conversions to individual plans regardless of pre-existing conditions (assuming prior credible insurance for a certain length of time). She can't be denied health insurance but it may be quite expensive ($1k+ a month). If you were to lose your job, again, HIPAA and COBRA programs would keep you and your spouse/dependants insured for at least 18 months (longer under certain circumstances).


While lack of health insurance isn't a reason to marry, a 3-day vacation to Vegas including license and Elvis themed ceremony can be had for much less than $1k.

Thanks. That summarizes what I think I've been reading. We can be insured no matter what, we'll just be paying quite a lot for it. The marriage thing was mostly a "current circumstances" plan where she has group coverage.

Now I need to figure out a ballpark figure for what it would cost to insure myself independently, in the event of emergencies, so that we can take that to salary negotiations.

SammyF

Darkewolfe wrote: »

Yeah, I agree with you there. I've paid into the system my whole life as a healthy person, and then one day I decided to get cancer. How dare I ruin the free money train that I was providing my insurance company.

Exact same thing happened to me, almost. My growth actually ended up being benign. They didn't care.

I don't smoke, almost never drink, I'm not overweight, and my cardiovascular's so good that despite of family history of hypertension, my blood pressure usually runs just a hair lower than normal.

But you get one funny looking mole removed....

Deebaser

Creidhes wrote: »

HIPAA regulations do cover conversions to individual plans regardless of pre-existing conditions (assuming prior credible insurance for a certain length of time). She can't be denied health insurance but it may be quite expensive ($1k+ a month).

Unfortunately, this isn't true. I am 99.999999% sure that creditable coverage only extends from group to group or from SOME individual policies to group. It doesn't qualify group to individual. However that isn't all that important in Dark's state because Virginia isn't guaranteed issue. They can deny individual policy coverage to anyone for any reason and permanently exclude whatever the hell they want.

Creidhes wrote:

If you were to lose your job, again, HIPAA and COBRA programs would keep you and your spouse/dependants insured for at least 18 months (longer under certain circumstances).

This is an excellent point. Assuming you guys are getting married in 18 months, it might be best for her to keep her old insurance under COBRA. With COBRA you're basically paying the group rate her old employer pays (plus a max of 5% (i think) if their broker charges an admin fee). Depending on what type of quotes you get with individual policies this may be insanely cheaper.

Dropping Loads

Creidhes wrote: »

While lack of health insurance isn't a reason to marry, a 3-day vacation to Vegas including license and Elvis themed ceremony can be had for much less than $1k.

I asked my wife if we could sign the marriage paperwork early so I would still be eligible for student-section college football tickets at the school I'd just graduated from .

Feral

Deebaser wrote: »

Creidhes wrote:

If you were to lose your job, again, HIPAA and COBRA programs would keep you and your spouse/dependants insured for at least 18 months (longer under certain circumstances).

This is an excellent point. Assuming you guys are getting married in 18 months, it might be best for her to keep her old insurance under COBRA. With COBRA you're basically paying the group rate her old employer pays (plus a max of 5% (i think) if their broker charges an admin fee). Depending on what type of quotes you get with individual policies this may be insanely cheaper.

Strongly agree. You can get the individual quotes anyway, but you may be better off with COBRA.

In fact, if your next employer will subsidize your COBRA payments, this may be the best of both worlds.

adytum

God dammit.

I'm on an individual plan (about to be an individual family plan) in VA through my employer, exactly how Darkewolfe is describing.

I have the best coverage money can buy, and it still sucks. Dental pays for about 15% of a routine visit. No vision benefits, obviously.

Also, I knew VA had horrible state regulation of health care (just like VA has horrible state regulation of everything else) but I was blissfully ignorant until this thread.

Creidhes

Deebaser wrote: »

Creidhes wrote: »

HIPAA regulations do cover conversions to individual plans regardless of pre-existing conditions (assuming prior credible insurance for a certain length of time). She can't be denied health insurance but it may be quite expensive ($1k+ a month).

Unfortunately, this isn't true. I am 99.999999% sure that creditable coverage only extends from group to group or from SOME individual policies to group. It doesn't qualify group to individual. However that isn't all that important in Dark's state because Virginia isn't guaranteed issue. They can deny individual policy coverage to anyone for any reason and permanently exclude whatever the hell they want.

Creidhes wrote:

If you were to lose your job, again, HIPAA and COBRA programs would keep you and your spouse/dependants insured for at least 18 months (longer under certain circumstances).

This is an excellent point. Assuming you guys are getting married in 18 months, it might be best for her to keep her old insurance under COBRA. With COBRA you're basically paying the group rate her old employer pays (plus a max of 5% (i think) if their broker charges an admin fee). Depending on what type of quotes you get with individual policies this may be insanely cheaper.

It is absolutely true. This is the purpose of HIPAA. If she is HIPAA eligible, private insurers cannot turn her down for an individual policy. The insurance companies are not required to offer her a family policy however (so the OP would be SOL). If she is not HIPAA eligible, then certainly they don't have to give her anything (as you posted, VA is not a guaranteed issue state).

The specific HIPAA eligibility requirements are here: http://www.cms.gov/HealthInsReformforConsume/Downloads/HIPAA_Eligibility_Criteria.pdf

Deebaser

I stand corrected. Its individual to individual that gets fucked, not group to individual. I bow to your superior knowledge of HIPAA.

Creidhes

Deebaser wrote: »

I stand corrected. Its individual to individual that gets fucked, not group to individual. I bow to your superior knowledge of HIPAA.

I've just suffered through Virginia shenanigans once too many.
And I'm going back for more!!

zauper

Of course, if insurers in VA turned you down, you could look into the VA high risk pools. I don't have time to look into it right now, and I don't know if the state itself has one, but of course the PPACA legislation required the feds to set one up in all states by... eh, a month ago maybe? So there should be one now.

Edit: quick google shows VA doesn't have a state HRP. I'm not sure if HHS has finished the setup of their plans or not.

That said... high risk pools are very very expensive and tend to have waiting lists. Not a good option either, unfortunately.

Being HIPAA eligible, unfortunately, isn't going to do a lot for you in the premium area either.

Kakodaimonos

Virginia is one of the states opting out of creating their own high risk pool. You'll have to go for the Federal high risk pools.

And isn't Virginia one of the states suing the feds over the new healthcare laws? I wouldn't expect them to do much to support any of the new regs until that gets settled.

Savant

Here's a bit of information about the high risk pool (Federal) set up for Virginia. It looks like it is a bit of a pain to be qualified for it and you have to jump through the hoops of the individual insurance market and lose coverage, but the prices are pretty reasonable (they are less than what I pay).

So if all else fails there is that.