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soupcxan · 11-15-2011, 07:20 PM

DW and I are thinking of getting pregnant. I am also adding her to my company's health insurance plan because it's better for this sort of thing than her company's plan (which she is on currently). Although I have enrolled her in my plan, coverage doesn't start until Jan 1, 2012.

So, my question is, if she becomes pregnant before 2012, but hasn't gone to see a doctor yet, will they be able to tell that conception occured in 2011 and then deny coverage as a pre-existing condition? This is not really a question I want to ask HR, for many reasons.

W2R · 11-15-2011, 07:28 PM

That's a huge risk, it seems to me. Although I have no inside knowledge of the health insurance industry, I would not have taken a risk like that even 40 years ago before our health care system was such a mess. It's only a month and a half.... you can wait, right?

By the way, congratulations on coming to this stage in your life and congratulations in advance for your little one soon to be on the way.

lucija · 11-15-2011, 07:37 PM

I am not an expert here, but can offer my experience.

I switched plans mid pregnancy, from one group plan (mine) to another (husbands) without any gap in coverage. I did not run into any issues.

There should be no issues moving from one group plan to another - I think HIPAA regulates this...

dgoldenz · 11-16-2011, 12:59 AM

Shouldn't be an issue if you have sufficient prior coverage or it's an HMO plan.

pb4uski · 11-16-2011, 07:18 AM

I think the insured event is the doctor visit and the delivery, not getting pregnant, but it would be wise to check.

The reason I say that is because when DD was in womb my employer changed our coinsurance and deductibles and the effective date was the beginning of the month that DD was due (Feb 1). I appealed that the delivery should be subject to the old coinsurance and deductibles since it was pre-existing, but they said no.

DD was born 5 days after the change so it cost me an additional $1,000 which was not chump change at the time. DD was worth the extra $1,000 though (most days anyway).

haha · 11-16-2011, 08:17 AM

If there were ever a pre-existing condition it is pregnancy prior to childbirth! Even Mary was known to be pregnant prior to the birth of Jesus.

Ha

Texas Proud · 11-16-2011, 08:51 AM

None of the group plans I have been with had any exclusion with pre-existing conditions...

**Alan** · 11-18-2011, 12:43 PM

Quote:

Originally Posted by Texas Proud

None of the group plans I have been with had any exclusion with pre-existing conditions...

I personally know of 4 employer group plans and none of them had exclusions of pre-existing conditions. OP will be unlucky if his company plan had an exclusion for already being pregnant when the transfer happens, even though I can see the POV of the insurance company.

foxfirev5 · 11-18-2011, 05:14 PM

I haven't been pregnant lately, nor has DW but have experienced this situation. I paid totally, on the installment plan, for two of our three kids. Both were of prexisting pregnancy before employment. However maybe we've progressed from the '70's regs and rules.

dgoldenz · 11-18-2011, 08:41 PM

Depending on the size of the employer, there can be a pre-ex clause for PPO plans. Usually this will apply to groups with less than 50-99 employees. Mega-corps don't have the same issue because of the size of the group.

Martha · 11-18-2011, 09:31 PM

Quote:

Originally Posted by soupcxan

DW and I are thinking of getting pregnant. I am also adding her to my company's health insurance plan because it's better for this sort of thing than her company's plan (which she is on currently). Although I have enrolled her in my plan, coverage doesn't start until Jan 1, 2012.

So, my question is, if she becomes pregnant before 2012, but hasn't gone to see a doctor yet, will they be able to tell that conception occured in 2011 and then deny coverage as a pre-existing condition? This is not really a question I want to ask HR, for many reasons.

Frequently Asked Questions about Portability of Health Coverage and HIPAA

Someone needed to answer your question.

REWahoo · 11-18-2011, 09:33 PM

Quote:

Originally Posted by Martha

Frequently Asked Questions about Portability of Health Coverage and HIPAA

Someone needed to answer your question.

Martha, back from the ~~dead~~ boondocks!

Nice to have you drop by. Can you stay for a while?

soupcxan · 11-19-2011, 06:59 AM

Quote:

Originally Posted by Martha

Frequently Asked Questions about Portability of Health Coverage and HIPAA

Someone needed to answer your question.

Thanks, although I thought I read somewhere that each state's hipaa rules could vary from the federal one, so I'm not sure if the situation in Texas is different.

**MichaelB** · 11-19-2011, 07:29 AM

Quote:

Originally Posted by soupcxan

Thanks, although I thought I read somewhere that each state's hipaa rules could vary from the federal one, so I'm not sure if the situation in Texas is different.

From KFF Maternity Care - Texas - Kaiser State Health Facts

Quote:

The vast majority of group health plans provide coverage for maternity care, including prenatal care. This is due in large part to the Pregnancy Discrimination Act of 1978 (PDA), an amendment to Title VII of the 1964 Civil Rights Act, that prohibits discrimination based on gender, pregnancy, childbirth, or pregnancy-related conditions. The PDA requires health plans sponsored by employers with 15 or more employees to cover pregnancy, childbirth, and pregnancy-related conditions in the same way as other temporarily disabling conditions. Though the PDA is not a mandated benefit law, per se, it has the effect of promoting maternity coverage under most employer-sponsored health plans. Enactment of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) effectively broadened the reach of the PDA. HIPAA requires all health insurance policies for small employer groups (defined as firms with 2 to 50 employees) to be sold on a guaranteed issue basis. This means small employers not subject to the PDA nonetheless have the opportunity to buy policies with maternity benefits sold to larger employers.

Texas insurance regs regarding pre-existing conditions and people moving from one group plan to another group plan Your Health Care Coverage

Quote:

Your waiting period is reduced on a month-for-month basis. If previous coverage lasted 12 months, there is no waiting period for an employer group plan. However, coverage is only required at the level of the prior plan. Carrier may not include a rider specific to the employee that eliminates coverage for the preexisting condition.

So, if she has had coverage for 12 months, moves into your group plan with no lapse in coverage, and your plan covers maternity, the insurance company cannot exclude coverage.

Martha · 11-19-2011, 07:51 AM

Quote:

Originally Posted by soupcxan

Thanks, although I thought I read somewhere that each state's hipaa rules could vary from the federal one, so I'm not sure if the situation in Texas is different.

No, federal law trumps. (Though state law can be more generous). Sometimes federal law doesn't regulate a specific issues or gives options to states but if HIPAA says x then x governs. So, HIPAA says if a group plan provides maternity benefits it must do so with no preexisting condition exclusions. Texas law on that issue is irrelevant if you are on a group plan. Once she is covered under your plan she is covered for the pregnancy. However, your plan can have a wait period before she can get on your insurance plan as HIPAA doesn't cover that issue, and apparently your plan does have a wait period and that is why she isn't covered until January. But that is different issue from a preexisitng exclusion waiting period.

Clear enough?