Pre-Existing Insurance question

[JoiseyMom]

I work at a major insurance company and I might be able to answer your question. With the new health care reform pre existing does not apply to anyone 19 and under, if the plan is grandfathered then it may apply so double check with the insurance company. For you and your husband they should be going off the hire date not the date you get the insurance. If the time between when he lost his job in July and when he is hired with his new job is less that 63 days you should be fine, as long as you have enough creditable coverage from your other policy. Most plans are 12 month for timely enrollee and 18 months for late, but again you would need to check with the insurance company. The hr department at the company should be able to help you or the insurance company maybe able to also.
If you do go over the 63 days the insurance will then establish if that was the first date of treatment for the condition you went to the provider for. (There is usually something that will flag their system based off the diagnois the provider bills on the claim.) They will ask for information from your provider t, also most plans have a look back period. Say you went to the doctor for back pain and the claim pends for pre ex and the provider said you were seen for back pain 12 months ago, if the plan has a 6 month look back that claim would not be pre ex. Also not all plans have a pre existing condition clause on there policies. If you know you are going to be going over the 63 days I would look into getting a short term policy. Most are inexpensive and they are fairly easy to get. Hope that helps.

I think from what I read, the plan is grandfathered..not sure about the pre exisitng..I want DH to contact HR once he is officially hired. The kids are both under 19. THere are no inexpensive options in NJ. I might be able to get a plan for 1 month about 900-1k. I had looked into but stopped because of another job offer..that never panned out..so I have to check it out again. Thanks.

 

[JoiseyMom]

From the point of view of a CEO who bought group insurance:

1) Check the name of the new insurance company.
2) MOST group policies DO NOT have pre-existing illness clauses.
3) MOST states DO NOT allow group policies to exclude pre-existing.
4) I do not know your new company or the insurance company.
5) But, after buying a lot of coverages, my bet is that you will be OK.

NOTE: I AM NOT A INSURANCE EMPLOYEE OR STATE INSURANCE
BOARD MEMBER. SO, THIS IS NOT A GUARANTEE. IT IS ONLY AN
ASSUMPTION FROM MY PREVIOUS EXPERIENCES. CHECK WITH THE
NEW INSURANCE COMPANY.

The old and new insurance company are the same...just different plans.

 

[JoiseyMom]

If you think you can't afford that then you DEFINITLY can't afford to be without coverage- and since you know your DH has a new job it's even worth taking on $1600 worth of debt for 3 months. Young cancer patient here too- my surgery pre insurance was 40k for less than one day in the hospital.

It's not 1600...it would be 4800 for 3 months...and I won't go into debt for that.

 

[JoiseyMom]

In NJ, you cannot be denied coverage for any pre-existing medical condition if you purchase insurance on your own and have a lapse in coverage. I am ignorant on the Obamacare thing, but as an adult with asthma and other previous issues,the laws in this state won't allow denial.

Hope it stays that way here

Even if the policy is from PA?? But I wouldn't be purchasing it on my own..it would be from his company as of Nov 1.

 

[stm61]

I applied for the NJ kids health care in NJ. The web site says you have to be without insurance for 3 months...they are processing us, so I have no idea if we will get it or not. He also has severance that runs out in 2 weeks, so we technically have income, even if it is just temporary.

If you get turned down because his income is to high, just call them back after his severance pay stops and tell them you now have no income. That's what happened to us once. My husband was waiting on one paycheck, since they always paid 2 weeks after the work was done, and they said it put us over the limit. I called back after the last check came in, told the caseworker he now had zero income, and she reprocessed the paperwork. We had medicaid cards for the kids a few weeks later.

 

[Swan4Me]

From the point of view of a CEO who bought group insurance:

1) Check the name of the new insurance company.
2) MOST group policies DO NOT have pre-existing illness clauses.
3) MOST states DO NOT allow group policies to exclude pre-existing.
4) I do not know your new company or the insurance company.
5) But, after buying a lot of coverages, my bet is that you will be OK.

NOTE: I AM NOT A INSURANCE EMPLOYEE OR STATE INSURANCE
BOARD MEMBER. SO, THIS IS NOT A GUARANTEE. IT IS ONLY AN
ASSUMPTION FROM MY PREVIOUS EXPERIENCES. CHECK WITH THE
NEW INSURANCE COMPANY.

This is correct
When DH switched jobs that did not offer dependant Ins-
I had a personal High deductable ins for 3 years that did not cover pre-existing
Then DH got a job with group Ins and my pre-exist is covered

 

[Princesca]

To be safe, I would just go to Anthem.com or something and buy the cheapest plan you can find. That way, you'll have continued coverage and will likely be covered in the event of anything truly catastrophic.

We did that for a few months after a relocation, and it really wasn't expensive.

 

[JoiseyMom]

Here are your rights under the laws:

http://www.dol.gov/ebsa/newsroom/fshipaa.html

Get a certificate of creditable coverage and have it applied to your new policy. Even though you are past the 63 day window you should still get come credit toward pre-x clauses.

On another note, are you past the election time limits on COBRA election? (since he's only been unemployed since July probably not) Did you decline it? Did you know that under the law you can elect COBRA just for your DH?

If you are still within the window to elect, then add up your costs for medical coverage since July - how does that compare for DH for a single (instead of family) policy? Elect just the single policy - pay for that and then you can submit for the bills you had for DH to offset the cost of the policy.

We are still in our Cobra window. The only med expenses has been 79.00 for DH. I renewed all the meds I could before the date. And I had a free coupon DS's ADHD meds for the past month. THe next script will cost me about 90.00 (and that is with a 1/2 program from the pharma company).

I am not worried about the med costs for the past few months. I am concerned if the new insurance will cover pre existing since I will be beyond the 63 day window.

If all goes well (with my life it doesn't usually), and DH starts in a week, he can ask HR about their policy. If I have to the cheapest I can find is 748 for family coverage for 1 month. SO we might just do that....

 

[JoiseyMom]

To be safe, I would just go to Anthem.com or something and buy the cheapest plan you can find. That way, you'll have continued coverage and will likely be covered in the event of anything truly catastrophic.

We did that for a few months after a relocation, and it really wasn't expensive.

We don't have them in NJ.

 

[JoiseyMom]

Ok..to those still here and who have given advice... DH will be working in PA, so the insurance is from that state... so which laws are in effect? NJ where we live and will use the coverage, or PA where the company policy is??

 

[Normangirls]

I work at a major insurance company and I might be able to answer your question. With the new health care reform pre existing does not apply to anyone 19 and under, if the plan is grandfathered then it may apply so double check with the insurance company. For you and your husband they should be going off the hire date not the date you get the insurance. If the time between when he lost his job in July and when he is hired with his new job is less that 63 days you should be fine, as long as you have enough creditable coverage from your other policy. Most plans are 12 month for timely enrollee and 18 months for late, but again you would need to check with the insurance company. The hr department at the company should be able to help you or the insurance company maybe able to also.
If you do go over the 63 days the insurance will then establish if that was the first date of treatment for the condition you went to the provider for. (There is usually something that will flag their system based off the diagnois the provider bills on the claim.) They will ask for information from your provider t, also most plans have a look back period. Say you went to the doctor for back pain and the claim pends for pre ex and the provider said you were seen for back pain 12 months ago, if the plan has a 6 month look back that claim would not be pre ex. Also not all plans have a pre existing condition clause on there policies. If you know you are going to be going over the 63 days I would look into getting a short term policy. Most are inexpensive and they are fairly easy to get. Hope that helps.

Ditto all of this^.

This is a very confusing issue. My take on a few things (based on 16 years of benefits management experience):

1. COBRA is expensive (and employees should keep in mind that is what their employer pays every month for their policy), but with on-going medical conditions it may be cheaper than the alternative -- that is, paying out of pocket for your medical care.

2. If you purchase an individual policy, make sure it is creditable coverage (the agent/broker should be able to tell you) or it won't count to exempt you from pre-existing condition exclusions when you sign up with another group/employer-sponsored policy.

3. I respectfully disagree that most groups do not have pre-existing exclusions -- I've never had a policy that didn't. Maybe the person who shared that has been lucky, or maybe his/her state regulates such exclusions, but I believe most plans include it. The thing is, until you get your new insurance (hopefully this job pans out for you and it is soon!) you won't know until you see the new employer's plan.

4. disneymamato2 mentioned this above -- if you go more than 63 days without coverage then you may have pre-existing conditions excluded. That clock starts ticking the first day you are without coverage and stops on the first day of employment at the new job (not when your benefits become effective 2-3 months later). So, like intheworks mentioned, maybe you could get COBRA for just long enough to keep your lapse in coverage under that 63 day limit.

5. If your husband was at his job for less than 18 months, that could come in to play as well, depending on how the new policy is written. As 3boymthr said, some of his dates of employment may give him credit to reduce his exclusion period; on the other hand, if he only had coverage for 6 months it may cause the exclusion to kick in (regardless of the 63 day rule).

6. Each policy is different. Just because two employers use the same insurance company does not mean they are the same, or even similar. My husband and I both have MMO at our respective employers, but the policies are completely different.

7. I'm not sure if this is just me, or if it is very common, or if it is federal regulation, but my experience with COBRA has been that you have to pick up the plan you had when you left your employer. You cannot just drop it from a family policy to an individual policy (except in other situations, none of which apply to what you're going through).

In any case, all this goes back to my original statement -- this is a very, very complicated issue. Maybe the best thing you could do would be to talk to an insurance agent/broker who you trust.

Sorry you're going through all this -- will send pixie dust and prayers that he gets the new job!

 

[JoiseyMom]

Ditto all of this^.

This is a very confusing issue. My take on a few things (based on 16 years of benefits management experience):

1. COBRA is expensive (and employees should keep in mind that is what their employer pays every month for their policy), but with on-going medical conditions it may be cheaper than the alternative -- that is, paying out of pocket for your medical care.

2. If you purchase an individual policy, make sure it is creditable coverage (the agent/broker should be able to tell you) or it won't count to exempt you from pre-existing condition exclusions when you sign up with another group/employer-sponsored policy.

3. I respectfully disagree that most groups do not have pre-existing exclusions -- I've never had a policy that didn't. Maybe the person who shared that has been lucky, or maybe his/her state regulates such exclusions, but I believe most plans include it. The thing is, until you get your new insurance (hopefully this job pans out for you and it is soon!) you won't know until you see the new employer's plan.

4. disneymamato2 mentioned this above -- if you go more than 63 days without coverage then you may have pre-existing conditions excluded. That clock starts ticking the first day you are without coverage and stops on the first day of employment at the new job (not when your benefits become effective 2-3 months later). So, like intheworks mentioned, maybe you could get COBRA for just long enough to keep your lapse in coverage under that 63 day limit.

Ok...Our last day of insurance coverage was July 31. If all works out well his start date is Sept 19, but we won't be eligible for insurance coverage until Nov 1. So, that means even though we won't be covered that we will still be within the 63 day window???

5. If your husband was at his job for less than 18 months, that could come in to play as well, depending on how the new policy is written. As 3boymthr said, some of his dates of employment may give him credit to reduce his exclusion period; on the other hand, if he only had coverage for 6 months it may cause the exclusion to kick in (regardless of the 63 day rule).

6. Each policy is different. Just because two employers use the same insurance company does not mean they are the same, or even similar. My husband and I both have MMO at our respective employers, but the policies are completely different.

7. I'm not sure if this is just me, or if it is very common, or if it is federal regulation, but my experience with COBRA has been that you have to pick up the plan you had when you left your employer. You cannot just drop it from a family policy to an individual policy (except in other situations, none of which apply to what you're going through).

In any case, all this goes back to my original statement -- this is a very, very complicated issue. Maybe the best thing you could do would be to talk to an insurance agent/broker who you trust.

Sorry you're going through all this -- will send pixie dust and prayers that he gets the new job!

How I have not had a breakdown is amazing....LMAO! He had an awesome job offer less then 3 weeks after his last job ended...but due to our lovely gov't (long story), the offer fell through. So even though he has an offer, until he actually starts...we are not getting our hopes up...LOL. Thanks for all the advice and the pixie dust...with all the stuff going wacko and not so great we can use it!

 

[Tink-aholic]

We don't have them in NJ.

Anthem is Blue Cross Blue Shield, the largest private insurer in the US (it has reciprocating agreements with 47 states). In NJ it is called Horizon BCBS of NJ...though I wouldn't check with them first because they are usually "cadillac" plan providers and have the pricetags to match.

Follow Normangirls' advice and make sure that if you buy an individual policy, it is for credible coverage.

If you are employed, I haven't heard anyone advise you that this is a qualifying event to enroll in the insurance plan offered at your employer -- though the window is only open for a short time.

Also, I understand the reluctance to go into debt for insurance premiums...especially if they are never really needed. However, if they ARE needed and you took that risk to be without insurance for that period of time, your debt could be monstrous. Look at some of the numbers on this thread; we're talking several digits beyond the premium cost.

Insurance is no different than legal gambling...you just have to make a decision and hope it was the right one.

Whatever happens, good luck.

 

[Normangirls]

Yes, since your insurance ended 7/31 and his new job (fingers crossed, pixie dust, and prayers!) is GOING to start (thinking positive) 9/19, you'll have a less-than-63-day lapse in coverage. If your new insurance policy is written in the standard way, they will not exclude pre-existing conditions once your coverage starts.

When he signs up for insurance at his new job (that he is GOING to get!), they may ask for a Certificate of Creditable Coverage from his old policy -- you'll contact the old insurance company and they'll mail that to you.

Good luck!

 

[JoiseyMom]

Yes, since your insurance ended 7/31 and his new job (fingers crossed, pixie dust, and prayers!) is GOING to start (thinking positive) 9/19, you'll have a less-than-63-day lapse in coverage. If your new insurance policy is written in the standard way, they will not exclude pre-existing conditions once your coverage starts.

When he signs up for insurance at his new job (that he is GOING to get!), they may ask for a Certificate of Creditable Coverage from his old policy -- you'll contact the old insurance company and they'll mail that to you.

Good luck!

Even though the coverage won't start until Nov 1???? I know you have said it...but logically it doesn't make sense! lol

 

[disneymamato2]

Even though the coverage won't start until Nov 1???? I know you have said it...but logically it doesn't make sense! lol

They should be going off the hire date not the date that the insuance starts. At least that was what happened at the three insurance companies I worked for. Also I know people mentioned State Mandates, if the the policy is self funded it will not follow state mandates, but it will follow federal mandates. I think you mentioned that this policy is with the same company you had before. When you get the insurance call them and see if they can just look at your old policy and see what your creditable coverage amount is. You could also try and call them now and see if they can pull up the coverage information for the new company. They can check to see if there is prex on the new policy, most policies I deal with have some short of prex exclusion. If you need it you should have received a certificate of creditable coverage letter from the old company, if you don't have it they can always send you another one. Good Luck hope everything goes well.

 

[Normangirls]

Even though the coverage won't start until Nov 1???? I know you have said it...but logically it doesn't make sense! lol

Um, this is a combination of federal regulations and insurance company policy language. Who said logic would have anything to do with it?

 

[JoiseyMom]

Um, this is a combination of federal regulations and insurance company policy language. Who said logic would have anything to do with it?

LMAO! I know...but in my former life I was a computer programmer....I think rather logically....kinda like Spock! LOL!!!

I will discuss with DH, and then check with Insurance Company once he starts and we can get some info from HR. I also am hoping since I have already paid them 3k in deductible that I don't have to start over for the last 2 months of the year!!

Between health insurance companies and home owners...I am going crazy! Need to call them on Monday too to find out the status of our house claim!

 

[j's m]

This is the explanation from our NJ BCBS small group plan for 2 to 50 employees. I'm not sure if the language changes for large groups.

This plan includes a 'pre-existing conditions' limitation. In general, a
pre-existing condition is a medical condition diagnosed or treated during
the six months prior to a covered person's enrollment date. It applies to
groups of two to five eligible employees, and to late enrollees in groups of
six or more. (A late enrollee is a person who failed to enroll within 30 days
of becoming eligible.) If a pre-existing condition exists, no benefits will be
paid for it for 180 days after the enrollment date. The 180 days may be
reduced by the time the person was covered under certain other health
care coverage (Creditable Coverage) that was continuously in force to a
date not more than 90 days prior to the enrollment date. Some exceptions
apply to this limitation, e.g., it does not apply to covered persons under age
19 or younger; pregnancy; a child's birth defect; genetic information, in the
absence of a diagnosis of the condition related to that information; or an
adopted child or a child placed for adoption.

 

[sookie]

its not hire date.
its lapse in coverage date.
you have to look at the dates that he is without coverage. To be safe you need to get a policy to cover you. you 63 days from 7/31/11 to get coverage - that should be about the beginning of october. I'd buy the coverage asap - get catastrophic coverage. It is cheap with high deductable.
That way if something WERE TO HAPPEN - you would have some coverage.