Speechless about what I learned re pre-existing cond. & insurance

Hi all,

Sorry I haven't been around much lately, but have had so many personal issues that I'm dealing with, that I haven't had the energy.

Great thing about FB is having so many of you for friends that we can at least see what is going on with each other, although we don't have to chat if we don't feel well enough.

Most of you know that because of my divorce and getting a new job, I do not have health insurance. Also, the best doctor that I have ever had, left the practice and so I don't have a Dr.

Well, open enrollment for health insurance opened up this month. I am eligible. I have to pay half (which with what I make is a lot of money that I don't have) and the company pays the other half. First have to meet a $500 deductible.

Got a call from the insurance company this morning telling me that because of my pre-existing condition that I cannot be seen for my migraines for 1 year. Or, I should say, my insurance won't cover my pre-existing condition or scripts for one year. I still have to pay the insurance for the whole year - but can't use it. Now, is there something REALLY wrong with this picture?? Was told it was part of the new health care bullsh$$.

So, I'm up a creek, no Dr., no insurance for a year, no meds.

What can I do? Is there anything I can do? Have any of you heard about this?

Thanks for any info anyone can give me.

yeah, I've heard it. It just sucks!!! You just get sicker then when you are covered the insurance has to pay for a more deteriorated condition. If they covered you from the beginning, you might actually be healthier and less of a "drain" on resources. It is counter-intuitive and BS.

Hi lostinobx,

I'm a frequent reader of this forum, having suffered with chronic (and so far untreatable) migraines for 6 years. I very rarely post though, as my migraines leave me with so little energy for writing. But I saw your question, and having been through the insurance maze, I know how confusing & frustrating it can be, so I wanted to reply & hopefully offer at least a little helpful into.

First thing, when you say that the insurance company told you the 1 year exclusion was due to "the new healthcare bullsh$$", I assume by that you mean the new healthcare reform law that passed earlier this year? If that's what they told you, they're mistaken. What's happening to you is, unfortunately, a very old practice.

It has long been the practice of insurance companies to impose a "waiting period" for coverage of pre-existing conditions (or even to attempt to exclude coverage for pre-existing conditions altogether). Because of this, when the HIPAA law was instituted in 1996, portions of that law attempted to impose some restrictions on these practices. So under HIPAA, insurance companies are only allowed to exclude your pre-existing condition for a certain length of time (usually a maximum of 12 months). And they are only allowed to look back 6 months prior to the time of your application, as far as what they can consider a "pre-existing condition" (so only something that you've been treated for in the 6 months leading up to your application can be called a "pre-existing condition). Additionally, you get "credit" for any insurance coverage you had previously, as long as your break from the last coverage is not more than 63 days to the time you apply for new coverage. So if you had health insurance continuously for a year, and it's been less than 63 days since that prior coverage ended, the new insurance company cannot exclude coverage of your pre-existing condition at all -- no waiting period. There are lots of details to this law and I don't know your specific situation, so the results will vary depending on your personal details, but you can probably get some help from this FAQ on the law here: http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

Also, some states have insurance laws that are even more helpful to the customer than the ones imposed by HIPAA (for example, certain states might say the maximum waiting period is 6 months, instead of 12 months. Or they may say your break in coverage can be 120 days instead of 63 days. So you should also look into the laws for your particular state, because they may be even more protective of you than HIPAA.

This link might also help you figure out your situation -- it gives a few more examples of how the HIPAA laws would apply to different scenarios: http://healthinsurance.about.com/od/healthinsurancebasics/a/preexisting_conditions_overview.htm.

As for the new health reform laws that passed this year, most of it has not gone into effect yet, aside from a few very narrow provisions (for ex. beginning this month, children cannot be excluded from their parents' health plan on the basis of pre-existing condition). None of the provisions dealing w/ adult pre-existing conditions have gone into effect yet, and when they do, they will make it so that adults can't be denied health insurance on the basis of pre-existing conditions either (this is a big deal if you don't get insurance from your employer, because right now it is very difficult to get insurance on the individual market if you have a pre-existing condition). So it certainly won't make things perfect, but hopefully it'll make things a little bit easier for people in our situation.

I don't know if the HIPAA law helps you at all since I don't know the details of your situation, but hopefully there will be something in there that makes a difference for you. I know how frustrating it can be to deal with insurance companies, and it's especially hard when you're already stressed & tired from not feeling well. Best of luck!

oh, one last thing, I know a lot of drug companies have programs where they help out people who can't afford their meds (I'm not sure if they give them for free or just a deep discount). These programs apply to people who don't have health insurance at all, but they might also apply to people who have insurance but aren't getting prescription drug coverage. I'm not sure about that, but it might be worth looking into. There are also drug discount cards you can get that won't make a huge difference but will decrease the cost of prescriptions a bit. There are some national ones, but also a lot of states or counties offer their own cards as well. Perhaps you could ask your local pharmacist about those or maybe even call one of your local congressman for help finding out about the discount cards.

I just saw your email, sweetie, and will reply soon.

For the record, I think it's important to know that this pre-existing condition problem is NOT part of the new health care reform. It's been around for a very long time. In fact, insurance companies used to be allowed to hold you to that for TWO years. Part of the health care reform provisions actually eliminate that, but parts of Congress managed to get the compliance deadline extended to, I believe, 2014.

One reason so many people have paid high rates for COBRA coverage when they were between jobs is that if you went from one group policy to another group policy, with no break in coverage, they couldn't slap you with a pre-existing condition clause.

Teri

lostinobx wrote:Hi all,

Sorry I haven't been around much lately, but have had so many personal issues that I'm dealing with, that I haven't had the energy.

Great thing about FB is having so many of you for friends that we can at least see what is going on with each other, although we don't have to chat if we don't feel well enough.

Most of you know that because of my divorce and getting a new job, I do not have health insurance. Also, the best doctor that I have ever had, left the practice and so I don't have a Dr.

Well, open enrollment for health insurance opened up this month. I am eligible. I have to pay half (which with what I make is a lot of money that I don't have) and the company pays the other half. First have to meet a $500 deductible.

Got a call from the insurance company this morning telling me that because of my pre-existing condition that I cannot be seen for my migraines for 1 year. Or, I should say, my insurance won't cover my pre-existing condition or scripts for one year. I still have to pay the insurance for the whole year - but can't use it. Now, is there something REALLY wrong with this picture?? Was told it was part of the new health care bullsh$$.

So, I'm up a creek, no Dr., no insurance for a year, no meds.

What can I do? Is there anything I can do? Have any of you heard about this?

Thanks for any info anyone can give me.

Yeah, Lulu got it right. The 1996 HIPAA law restricted how long you can be denied coverage for a pre-existing condition to 1 year. Before that, ti was longer. As she said, this pre-existing clause goes into effect if you have been without coverage for 63 days ( 31 in some cases). Various states extended the period you can be without coverage. Not mine, alas.

I was thinking about starting a business and looking into setting up a group plan, so had to study this. I'm afraid the group plan set up period would cause gaps in my insurance.

This and other stuff has me so worried that I am considering waiting until the "Obama-care" kicks in fully in 2014. At that point, it becomes much easier to get group insurance, so I won't have to set up my own plan, and preexisting conditions are eliminated.

It's funny that the "death panel" propaganda has so distorted the actual details of the health insurance reform, so that now people think the plan does the exact opposite of what it does. It's particularly disturbing that an insurance company representative took advantage of this propaganda to confuse you.

Maybe it's time to get "creative" with your diagnosis, ie, many companies will not cover botox injections for migraines but they WILL cover botox injections for stiff neck or neck pain.

Maybe this creative wording and a cooperative doc could help you through this year??

I'm sorry you are dealing with this. Yikes!

Lulu was quite right. When the new laws take effect you will be much better off. But a lot depends on what kind of insurance your company has right now. If it is a group plan usually they cannot deny for pre-existing conditions the way they can for individual plans. I make sure our company's plans do not do this. That does not mean I don't have to push back sometimes when they try to deny coverage for something. I recommend talking to your company's human resource director to see if the insurance plan can deny a new employee coverage for a pre-existing condition. The insurance company may not be telling you the truth. And if it is, that is a very poor plan your company has selected. Unfortunately the insurance companies have been jacking up the rates so much (we have had 10-25% increases every year for last 10 years) that many companies just can't afford decent insurance any more. Too bad the public option did not get into the law. It is the only thing that would have kept them remotely honest.

Myson was born 21 years ago with a rare genetic disorder. When hubby switched jobs they put riders all over my son "pre existing". So no...this practice is very old. Somebody is feeding you a line of hooey about this being part of the new plan. The new plan is seeking to eliminate discriminating coverage due to pre existing conditions.

I am very fortunate in that I have Government insurance that has never had the pre-existing clause. Amazing how govt. Employees don't have to worry about such things.

Thanks so much for all of your responses. Your information and advice means a lot.

I'm really hurting right now, but will try to explain a couple of things.

My employer has a group plan which was switched from Anthem to Southern Health. I have not been insured for 12 mths, due to divorce and not being eligible until now. He (ex) was suppose to cover me until I was able to get insurance with my new job. He didn't. He works for the Government as some of you know.

I have never had this problem before, I guess that's what is so frightening. Have always had pre-existing condition (migraines) and was never told that I had to wait a certain period of time.

Yesterday made me wonder, with so many people unemployed, with pre-existing conditions like Cancer for instance, what happens to those people when they get jobs and are eligible for insurance, but haven't had it for a year or more? It just seems wrong. Do they pick and choose which pre-existing condition is worse than another?

I have lots of research to do and thanks for giving me a starting place, but right now, I cannot imagine going for a year with this disease and not being able to be treated for it. And at the same time, paying for the insurance. I'm kind of scared not to pay it because it looks like until the health care bill is in place, I will still have to wait anyway.

Sorry if I don't make sense, just drained, scared, and more than anything, hurting like crazy.

Thanks again guys - you are the best and I knew I would get the answers and advice that I needed from all of you.

Hugs!

Howdy

First a BIG round of applause for Lulu ... GREAT post!!!! thank you,

Second, my friend, when I am in trouble thinking and doing with migraines episodes there are two things I do:

1. Make a List of tasks

You list is rather short:

A. Speak with your human resourse insurance person ,,,, face to face if at all possible.

Explain the situation and what the insurance company said.
Tell them you KNOW the insurance was lying about the new health care plan and you want to see if the 12 month rule is true.
IF the insurance does indeed impose a 12 month pre-existing rule, explain to the human resoources person that 12 months without treatment of your migraines is going to have a serious impact on your absenteeism and work performance - you fear. Tell teh HRM that if they call and get this 12 month thing out of the way for you, you will be able to be a more present and productive employee for the comapny. Remember, tie your request for an override to your much increased productivity at your job. Who knows, they may authorize an over ride IF the insurance is nto lying thru theirteeth.

B. If A fails, then open the phone book to the blue pages, state government. Contact the Insurance Commissioner for your state. Explain everything the insurance company said and what your HRM said. Again explain that the rule is preventing your full productivity at work. Ask you can file a complaint and have a resolution sought. They may cooperate, or at least tell you what other steps to take.

C, If the HRM fails you AND your state's insurance commissioner fails you, THEN

Make an appointment with a worker at your local state or county public assistance office. Explain that you have a serrious disease that is affeting your work and and, thus,the county/state's economy. Explain that you need your state's public assistance insurance for those 12 months solely to treat migraine. Who knows, you may get Medical in California oir your state's version thereof.

D. IF steps A, B, and C all fail,
Contact your employer's ADA coordinator. Tell that person that you want a "reasonable accomadation" for your disability of migraine disease ... i.e. insurance coverage. Who knows, you may win here.

E. If steps A, B, C, and D fail:
Contact your state representaitve or state senator and request assistance. Also call your Governor's office ombudsmen. Maybe they can cut thru the red tape for you.

With a list of If A then B steps in front of me, I find it much easier to deal with issues especially while disabled with migraines.

2. Get by with a little help from my friends

When I am having a bad time, I canot speak clearly on the phone. Oftentimes Steve or a friend will make the call on my behalf. You have relatives nearby who could work this list for you if you are bad off.

As always, I wish you nothing but well ... and CONGRATULATIONS on the new job! I KNEW you could do it ... she what a strong and beautiful woman you really are? Well done!

Wow, I wish I'd come here back when I was first dealing with health insurance issues of my own! You guys are great (though I already knew that from my years of lurking) and added tons of helpful information beyond what I mentioned..

Health insurance & the push for reform became sort of a pet issue for me, for reasons that are probably obvious to most of us here! I'm sure many of us have had to deal with insurance nightmares due to our chronic condition(s). (After the migraines forced me to leave my job, I had to navigate the individual insurance market in order to get coverage. That task was like a new full time job in itself & certainly taught me about a lot of things I'd had no clue about before!)

You guys are all so knowledgeable, and it's wonderful to see how willing everyone is to help out & share what they've learned from their own ordeals!

oh, and lostinobx, I'm really sorry that you're in the position you're in. It really stinks that your ex left you without coverage and that's led to your current dilemma. That just seems so unfair, since it was out of your control. But everyone else who posted here gave you some great suggestions about talking to Human Resources and also talking to some of your local politicians' offices. Hopefully it'll turn out that whoever you spoke with originally just gave you the wrong info, but if not, perhaps one of these other people in HR or in your local government will be able to help you. Best of luck & let us know how it turns out!

Richard,

As usual your info is awesome. I plan on doing some of the things that you mentioned. Our company is family owned, with only one owner (son) now, and he is our HR. Not very understanding in things like this, at least not like his father was before he passed away.

So, will try talking to him to see if it gets me anywhere... Then will go to the next steps you mentioned. And Richard, your compliments made my day, as always. You are truly a blessing to those of us here, as is all of our members!

Lulu - I can't thank you enough for your info and your support. Please, don't stay a lurker any longer. Your knowledge and understanding is what this forum is all about - that and the wonderful people who belong. Thank you so much!!

Will keep you updated. As you can imagine, my migraines are back, very bad. It's taking everything that I can to come to work, but I don't have a choice, I'm in debt.

Hugs to all of you!!