The Preexisting Condition Clause

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The Preexisting Condition Clause

You may find that a condition you are being treated for under your current plan, may not be covered under your new plan. This is called a preexisting condition. Pre-existing conditions can vary between plans from being excluded to being covered fully and sometimes somewhere in-between like being covered after a specific amount of time. The Health Insurance Portability and Accountability Act, www.cms.hhs.gov/HIPAAGenInfo, ensures coverage for pre-existing conditions if you are joining a new group plan from your employer and you were insured the previous twelve months. Some plans impose“preexisting condition exclusion.” This means that if you have a medical condition before coming to our plan, you might have to wait a certain period of time before the plan will provide coverage for that condition. Be sure to check with your state HIPAA rules and compare them to your insurance plan to be sure there are no discrepancies. Some states offer a “guaranteed issue” which means that individuals insurers must sell coverage to all residents, others limit the length of exclusion periods. Other states have “community ratings” which impose rules that premiums cannot vary based on health status. The preexisting condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 30 days after birth, adoption, or placement for adoption. Some people, if they have the flexibility, might choose to move to a different state based on rule such as “community ratings” because it may be more cost effective.
If you are receiving insurance through your employer, he/she can decide what the plan may cover as long as they cover certain benefits. The employer cannot deny you of health insurance or offer you different insurance based on you health, but they can implement a “pre-existing condition of exclusion” or pre-ex period of no longer than 12 months. This pre-existing condition of exclusion cannot apply to pregnancy or newborns.
On the other hand, one can reduce their pre-ex period by showing proof of coverage from a prior insurer (this would be a certificate of creditability that documents you past coverage, or old ID cards or statements) as well as no break in coverage of 63 consecutive days.

   

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