Group Health Insurance Plans And Pre-Existing Conditions
When talking about group health insurance plans there is frequently confusion because, although some people say that group insurance plans are not allowed to exclude you from cover on the basis of your present health or your prior history, other people contend that they are allowed to refuse cover in the case of pre-existing conditions. So, what is the truth when it comes to pre-existing conditions health insurance coverage?
It is in fact true that you cannot be denied membership of a group insurance plan solely because of you present health, which includes any disability which you may have, or as a result of your past medical history.
Nonetheless, employers and insurers are entitled to ask you if you have any pre-existing medical conditions when you join a scheme or, if you submit a claim during your first year of coverage, to look back in order to establish whether you have a previous history of the condition which gives rise to the claim.
Whenever a pre-existing condition is either reported or discovered the employer or insurance company may not simply refuse you coverage under a group plan but is allowed to require an exclusion period for health insurance coverage for preexisting conditions. This said, there are federal and state laws which control the exclusions which employers and insurers are allowed to place on their group plans.
Group health insurance plans are not permitted to apply pre-existing condition exclusion periods on the basis of either pregnancy or genetic information. Further, exclusion periods are not allowed in the case of newborns, newly adopted children and children placed for adoption.
In general terms, pre-existing condition exclusion periods can only be imposed for conditions which are diagnosed within the 6 months prior to joining a group scheme and for which you have had (or been recommended to receive) treatment. This 6 month period is frequently called the 'look back' period.
If an exclusion period is imposed it cannot usually be longer than 12 months and you must be credited for any previous continuous creditable coverage. Here cover is said to be continuous as long as it is not interrupted by a break in excess of 63 consecutive days. The majority of private and government sponsored health coverage is classed as creditable and this will include such things as Medicare, student health insurance, foreign national coverage, Indian health insurance, individual health insurance, military health coverage, VA coverage, Medicaid and much more.
If an employer imposes a waiting period for individuals to enter a scheme, or an HMO imposes a similar affiliation period, these cannot be included in determining a break in continuous coverage. Further, pre-existing condition exclusion periods have to take into account the waiting or affiliation period with the pre-existing condition exclusion period beginning on the same day as the waiting or affiliation period.
If you are moving from one group scheme to another then the administrator of the new scheme is allowed to look at your old plan for the purpose of calculating any credit entitlement towards an exclusion period for your new plan. This could mean for example that if the new plan provides cover which was not provided under the previous plan then exclusion periods can be imposed for pre-existing conditions which were not formerly covered but which are covered under the new plan.
One final point worth noting is that you have to be given appropriate notice of any pre-existing condition exclusion period in writing and the group scheme administrator must assist you in obtaining a certificate of creditable coverage from your previous plan if you want him to do so.
Benefit design: The process an MCO uses to determine which benefits or the level of benefits that will be offered to its members, the degree to which members will be expected to share the costs of such benefits, and how a member can access medical care through the health plan.
Functional status: A patient's ability to perform the activities of daily living.
Preferred provider arrangement (PPA): As defined in state laws, a contract between a health care insurer and a health care provider or group of providers who agree to provide services to persons covered under the contract. Examples include preferred provider organizations (PPOs) and exclusive provider organizations (EPOs).
Quality management (QM): An organization-wide process of measur-ing and improving the quality of the health care provided by an MCO.
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