Any health insurance experts?

[Cringer]

I am trying to find an answer to a question, and I can't. Well, I may have but it is not 100% clear to me if it is my answer or not.

Some back story. After 7+ years with a company and their coverage I left that company in early November. Because of the high cost of my new companies insurance plan we decided to try to get our own health coverage. Big mistake. My wife was denied coverage. Because of this I bit the bullet and was in the process of getting my companies group coverage when, as you know if you read MacroGuru's Dream Job thread, the company ceased operations Friday.

As I now look for a new job or hope the old one reforms somehow, I am dealing with getting insurance after a good size gap, almost two months as of today. I have read about pre-existing condition exclusion periods, but everything I find pretty much talks about limiting those exclusions periods based on prior coverage. My question is this....

Can my wife be rejected outright by a group health coverage plan? I am not sure if I found an answer to this or not. I found this, and this is the only thing I can find. It is on healthinsurance.about.com.....

Other consumer protections - Employer-sponsored health plans cannot discriminate against you if you're sick by refusing to let you in the plan or by charging you more for coverage. In addition, group plans must offer you a special 30-day chance to enroll if you have a change in family status (e.g. if you marry or have a baby) or if you lose other coverage (e.g. that your spouse may have had through his or her job.) Finally, group plans must limit the imposition of pre-existing condition exclusion periods to no more than 12 months and they credit prior coverage you've had toward a new pre-existing condition exclusion period.


I take that to mean she can't be rejected coverage, but will probably have a pre-existing condition clause slapped on her. Does this sound right?

And let me say this again, I am out of work right at this second. So COBRA, which I could still get I think, will absolutely kill me financially. Also, if I was working I would call up HR and ask them because they could probably get me the exact answer I am looking for. I don't have an HR dept. to ask now though.

Thanks in advance for any help.

[beargrowlz]

Best thing to do is call the office of your state's Insurance Commissioner. As federal law only covers certain, limited aspects of insurance, your state's Commissioner should be able to answer any specific questions you have regardiing this situation.

Hope that helps.

[Cringer]

Best thing to do is call the office of your state's Insurance Commissioner. As federal law only covers certain, limited aspects of insurance, your state's Commissioner should be able to answer any specific questions you have regardiing this situation.

Hope that helps.

Does it go by the state you live in, or the state your company is in, or something else? Chances are I will not end up with a job in which I live in my employers state, that is why I ask.

[beargrowlz]

The state the insurance company is operating in - so in essence the state of the employer's incorporation.

Which may or may not be the actual state you get the job in, as many major companies choose to incorporate in Delaware because of that state's extremely favorable laws regarding corporations.

For a smaller company, it'd likely be the state where that company is located - they wouldn't reap the benefits of incorporating in Delaware.

If you're inquiring about buying the health insurance yourself, that is without going through an employer, it would be the state you reside in because the insurance company would need to be licenced in your state to sell you insurance directly.

[Cringer]

If you're inquiring about buying the health insurance yourself, that is without going through an employer, it would be the state you reside in because the insurance company would need to be licenced in your state to sell you insurance directly.

Already tried that one. We were under the impression that our state laws prevented my wife being denied because she had been on my previous group coverage. She was denied though so I guess what we were told by our state was incorrect or two companies just ignored it and screwed us over.....

I hate insurance.

Thanks for the information though.

[BYU 14]

It is federal law that Group plans offer portability (credit for prior coverage and also gaurantee issue) if you have a qualifiying group plan. The main pitfall, and this varies by State (Which can modifiy Federal Statutes) is that you can only have a gap on coverage for so long to get a waiver on Prexisting conditions, this has to be researched through your State. Most of my experience is with commercial carriers and if I still worked for one I could get you a specific answer for your state. I now however work for an administrator of Medicaid plans, so the same rules do not apply, sorry.

In terms of Prex, if you qualify for portability, you will get credit for any period of continuous coverage towards meeting the new plan prex limitations (Standard is 12 Months, but can range from 6-18 as well) Im other words if you had nine months of Coverage prior, your Wife would only need to go 3 months subject to exclusion for prexisting conditions. 12 months of coverage or more and no Prex.

Another thing to keep in mind is the definition of the Prex limitation on the plan you are looking at. An example of wording here would be "Confinement or treatment, including medications, for any chronic condition during preceding 12 month period" Some also ontain waivers for "treatment free periods of 90 or 120 days" meaning if you wife had gone that amount of time without seeing a doctor or getting a prescription she would be off the hook.

The individual plan you looked at flat out turned your Wife down, which they can do as there is a difference between insurability and coverage of a Prexisiting condition, and depending on the State indivdual plans are not held to the same rules as group plans, as their risk pool is much smaller.

As you can see there are a lot of variables and the information above is pretty generic. If you want to send me a PM I can answer any questions you have or if you can get a copy, email me plan documents of a plan you may be looking at and I can review them for you. I know cobra is hellish expensive, but it can be applied retroactively and is sometimes worth it of the alternative is 12 months of costly medical bills, due to an exlcuded prex condition.

Let me know if I can be of any help buddy.

[lynchjm24]

Depends on how it's written. If it's a true group plan or something written through an association.

If it's a true group plan then the pre-existing condition rule will depend on what the plan sponsor is paying for. If you had 'credible coverage' within 3 months of joining then you shouldn't have to worry about pre-existing conditions, because of HIPAA, they wouldn't be able to not pay claims on pre-existing conditions.

For something to truly be a pre-existing condition per HIPAA then you must have not had credible coverage within 90 days, and you must have had prior treatment of the condition.

[lynchjm24]

Does it go by the state you live in, or the state your company is in, or something else? Chances are I will not end up with a job in which I live in my employers state, that is why I ask.

Completely depends on the funding arrrangement the plan sponsor uses. If it's fully insured then it's the state it is sitused in. This can be any state that the company employs someone who could sign the contract. So it doesn't have to be the headquarters state, it could be a more favorable site.

If it's self-funded by the plan sponsor then state insurance laws don't matter. They don't apply to self-funded business.

How big is the company? If it's more then 1k employees it's almost certainly self-funded unless it's a governmental type group.

[lynchjm24]

The state the insurance company is operating in - so in essence the state of the employer's incorporation.

Which may or may not be the actual state you get the job in, as many major companies choose to incorporate in Delaware because of that state's extremely favorable laws regarding corporations.

For a smaller company, it'd likely be the state where that company is located - they wouldn't reap the benefits of incorporating in Delaware.


None of this makes any sense or is true in anyway. The state of incorporation has nothing to do with where they can or can't write the insurance from.

[lynchjm24]

I'm pretty sure that you mentioned your wife joining an association program for real estate agents? If that is the case then you could end up in a situation where these could happen:

A. "Exclusionary Riders" - Companies like New York Life write a lot of association business where they can just not cover certain conditions using these riders (I know for a fact that NYL does this in Texas)
B. "Underwritten Up" - They will raise your rate above the group rate based on her medical underwriting
C. Excluded - This depends on the state it is written in and probably how the insurance company 'files'. In some states you could be excluded on an association plan. It also depends on the legal area of the carrier and how they interpret laws. I can tell you that my company interprets things much less liberally then some of our competitors.

[beargrowlz]

The state of incorporation has nothing to do with where they can or can't write the insurance from.

You're right, my bad. If they're writing a policy in New York state, they have to be licenced by the commissioner of NY state.

Thanks for the correction.<!-- / message -->

[Cringer]

I'm pretty sure that you mentioned your wife joining an association program for real estate agents? If that is the case then you could end up in a situation where these could happen:

A. "Exclusionary Riders" - Companies like New York Life write a lot of association business where they can just not cover certain conditions using these riders (I know for a fact that NYL does this in Texas)
B. "Underwritten Up" - They will raise your rate above the group rate based on her medical underwriting
C. Excluded - This depends on the state it is written in and probably how the insurance company 'files'. In some states you could be excluded on an association plan. It also depends on the legal area of the carrier and how they interpret laws. I can tell you that my company interprets things much less liberally then some of our competitors.

The insurance we tried to get through the National Assoc. of Self-Employed (Mega-Life was the insurance provider) outright rejected my wife. Wouldn't give her any coverage. We applied before my coverage had run out, they made their decision a couple weeks after it ran out.

We tried BC/BS after that because that was who my companies coverage (the coverage that just ran out) had been with. They rejected her outright too.

Nobody offered any pre-ex clause or anything. Just wouldn't cover her at all. She has barely even seen the doctor for her RA which is what is annoying. I understand the future is what they are concerned about but still it sucks because we had coverage before. It is not like she got it when we had no coverage and we decided to get insurance afterwards.

So, looking to go back to a group coverage plan offered by whatever company I end up going to, I am worried they could completely reject her too. That is my main question. I don't care if there is a pre-ex clause at this point, I just want to make sure she can get some kind of coverage.

[lynchjm24]

So, looking to go back to a group coverage plan offered by whatever company I end up going to, I am worried they could completely reject her too. That is my main question. I don't care if there is a pre-ex clause at this point, I just want to make sure she can get some kind of coverage.

True corporate group plans rarely medically underwrite the individual. Depending on how the pre-ex is written in their policy should be your only problem.

Associations are extremely bad risk, so there are very few players and they are very conservative.

[Cringer]

True corporate group plans rarely medically underwrite the individual. Depending on how the pre-ex is written in their policy should be your only problem.

Associations are extremely bad risk, so there are very few players and they are very conservative.

Thank you, that's good to know.