Ow. Ow ow ow ow ow ow ow ow ow OW!

[mykidslovedogs]

Originally Posted by Cute Fuzzy Bunny

See, thats where i'm a little bit confused. I thought that most short term 'gap' policies excluded prescription meds, and thats our biggest item. My wifes asthma has her on about $200-300/mo in prescriptions.

I don't think you would run into a problem with self-funding your Rx for the next two months and supplementing that with a short term policy. I have called Humana before, and they did tell me that the short term policies would count as creditable coverage for new enrollees coming off of a waiting period.

I'll have to check on EBIA and see if I can find any precedence on that question. I'll let you know what I find out.

I'm going to call one of my buddies at Humana right now, and I'll let you know what I find out.

[mykidslovedogs]

I'm on the phone with Claims at Humana right now....

[mykidslovedogs]

Originally Posted by mykidslovedogs

I'm on the phone with Claims at Humana right now....

OK - They said that all they are concerned about is the fact that you had a medical plan in force during your gap. They don't care whether or not the 'gap' plan had prescription drug coverage or even coverage for the pre-existing condition for that matter.

Now, that's just what Humana said. I'm not sure about other carriers. To save yourself $1300, it might be worth a phone call to your wife's previous HR dept to see what they say. Just ask them if they can tell you what will count as creditable coverage. I'd be surprised if they won't count a short term policy. The HR people can call Kaiser to get a definitive answer.

[Freein05]

The break in coverage is 62 days. As Kaiser is going strictly by the regulations go to the following link it is the government web state and should answer all your questions. Do not depend on a third party unless it is an attorney. You have too much at risk.

http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html

[kramer]

The COBRA clock does not start ticking until you get the notification paperwork. For my Fortune 500, a separate entity handled this. So the clock did not start ticking until around 10 days after my termination. I don't know if this might give you a little leeway.

Kramer

[lets-retire]

I thought when I was on COBRA last year the policy was there could not be more than 62 day gap in coverage. As I understood it the gap stopped as soon as you entered the waiting period for insurance from you new employer.

[kramer]

I just checked my paperwork. I have a certificate of creditable coverage that goes through the date of my termination. I received this paperwork around 10 days after termination.

I received my COBRA notice about 10 days after termination, also. It says (they have actual dates, but I am just using something simpler below):

Date of Notice: My termination date + 10 days
Qualifying Event: My termination date
Benefits Termination: My termination date
Election Rights Expire: My termination date + 10 days + 60 days

The premium is due within 45 days of when your COBRA election is sent in.

So the COBRA clock may be slightly different than creditable coverage gap. Hope that helps.

BTW, as far as I know, my previous employer's insurance did not exclude any preexisting conditions for new employees. But I am not absolutely sure of this -- I just never saw it in any of the handbooks nor heard about it from any employee. I did not have to show a continuning coverage certificate when I started working there and switched health insurance even though I had not been employed immediately prior to taking the job.

Kramer

[mykidslovedogs]

Originally Posted by lets-retire

I thought when I was on COBRA last year the policy was there could not be more than 62 day gap in coverage. As I understood it the gap stopped as soon as you entered the waiting period for insurance from you new employer.

This is from the link that Free posted:

"Days in a waiting period during which you have no other coverage are not creditable coverage under the plan, nor are these days taken into account when determining a significant break in coverage (generally a break of 63 days or more). " Hmmm, the wording on that is a little confusing, but it sounds like you might be right, Let's. It sounds like days in a waiting period count neither for or against you as far as creditable coverage and gap time are concerned.

[Martha]

Be careful when talking about this stuff not to confuse what you have to do to activate COBRA and what you have to do to maintain credible coverage. Freein05 posted an excellent link regarding credible coverage and what counts. From the link:

Most health coverage is creditable coverage, such as coverage under a group health plan (including COBRA continuation coverage), HMO, individual health insurance policy, Medicaid or Medicare.

Creditable coverage does not include coverage consisting solely of excepted benefits, such as coverage solely for limited-scope dental or vision benefits.

Days in a waiting period during which you have no other coverage are not creditable coverage under the plan, nor are these days taken into account when determining a significant break in coverage (generally a break of 63 days or more). This 63-day break period may be extended under state law if your coverage is insured through an insurance company or offered through an HMO. Check with your State Insurance Commissioner's Office to see whether a longer break period applies to you.


So, as was explained several times by others, you don't want a break exceeding 62 days. As to how to count the days, I would count every day you do not have insurance, except waiting period days under the new plan. If the uninsured period began April 1, and she is covered under the new plan as of June 1, there are 30 days in April and 31 in May so there are 61 days of no coverage.

But ask HR. I hate to be down to the wire on these things.

To confuse things further, the time periods for electing COBRA are different and run from the date of the COBRA notice. That is a totally separate issue.

[Martha]

The best place to read all the California rules on these issues is this link, which I sent you before: http://www.healthinsuranceinfo.net/ca.pdf

There was mention of obtaining temporary insurance that may not have as broad coverage, but would be cheaper than COBRA. My understanding is that it is still credible coverage, but if the policy doesn't cover something, you will have a pre-exisitng condition waiting period for the non-covered items. For example, if it doesn't cover drugs, then you have to wait six months until your drugs are covered under the new plan.

[mykidslovedogs]

Originally Posted by Martha

The best place to read all the California rules on these issues is this link, which I sent you before: http://www.healthinsuranceinfo.net/ca.pdf

There was mention of obtaining temporary insurance that may not have as broad coverage, but would be cheaper than COBRA. My understanding is that it is still credible coverage, but if the policy doesn't cover something, you will have a pre-exisitng condition waiting period for the non-covered items. For example, if it doesn't cover drugs, then you have to wait six months until your drugs are covered under the new plan.

I called Humana claims to check on the answer to that question earlier, and they said that they would not put a pre-ex on you just as long as you had a medical plan in force during the gap. They said it wouldn't matter if the plan did not have coverage for prescriptions or for your pre-existing conditions.

BTW and this was interesting to me, because it has come up before, Humana said they don't impose pre-existing condition waiting periods on prescriptions. They said it's only for medical. I thought that was interesting. I suppose that might just be Humana's interpretation of creditble coverage, so I would definately want to check with the new carrier (Kaiser) and ask before doing anything.

Also, keep in mind that STM coverage doesn't have any coverage for pre-existing conditions, so, God-forbid, if she had an asthma attack and had to be hospitalized while on the STM plan, there wouldn't be any coverage for the asthma....even though you are pretty certain your only costs will be meds, that is something to take into consideration.

[kramer]

Martha: To confuse things further, the time periods for electing COBRA are different and run from the date of the COBRA notice. That is a totally separate issue.

Thanks for clearing that up!

Kramer

[mykidslovedogs]

Another Tidbit....

Martha, as always, is with no doubt correct on the legal interpretation of creditable coverage as far as pre-existing conditions go. If your "creditable coverage" did not have coverage for your pre-existing condition, then technically, the pre-existing condition could legally be ridered on the new plan.

However, in talking with Humana, it is apparent that different carriers have different interpretations of this rule regarding how they enforce that. Apparently, Humana does not impose pre-existing condition limitations on prescription drugs, but only on medical issues when there is a "gap" in coverage, and they don't care if your creditable coverage (prior coverage) had prescription drug coverage or not.

Obviously, the safest thing is to go with COBRA if you have a pre-existing condition, but if you think it might be worth the savings, perhaps it's worth a phone call to the new carrier to ask how they define creditable coverage when it comes to pre-existing condition limitations on the new plan. If all they require is proof that you had some sort of major medical coverage in force during the "gap", then a short term policy might suffice. Apparently, based on my conversation with Humana, some carriers don't even impose pre-existing condition limitations on prescriptions, but rather, just on the medical portion of the coverage, and some carriers don't even care if your "prior coverage" included coverage for you pre-existing condition. Some only care that you had a major medical plan in force in order for you to get credit towards pre-existing condition limitations.

[chinaco]

CFB - That is why we have been waiting to ER. The company Health benes. I figure the cost in todays dollars for company health benes is about 2k/yr in premium for DW and I. Luckily, we both have companies that give us benes so we have some redundancy. I am trying to determine how to optimize the cost.

If we went without it from 50 - 65, the PV would be huge (not to mention the opportunity cost). I made some rough estimates on premium (which the damage could be worse)... But I estimate the premium cost for that period for DW and I would be about $250k - $300k in present value (for 15 years RE @ 50). Our premium cost if we RE @ 55 will be approx 35k in present value (for 10 years RE @ 55). Even if we had to pay for both sets of health benes for redundancy (the total cost would be 70k PV for the 10 years RE @ 55) Of course, these are estimates based on some assumptions and one assumption is that we will be healthy. Otherwise that 250k could be more like 400k in premium (to RE @ 50). I made some steep health insurance inflation projections (10%). I did not get fancy with the PV, just used a 3.5% normal inflation factor.

While we could ER today. That expense eats into our planned discretionary spending. I would rather have the discretionary spending than ER 4.x years sooner. This should give us at least another 200k to spend from 55-65. Where we live... that is the cost of a decent house in an acceptable location!

This is the choice that each of us makes. Each person decides and makes the trade-off.

[cute fuzzy bunny]

Yeah Martha, you gave me the scoop already, but when I saw the $2600 bill, I started looking for ways to weasel out of it.

Interestingly, I called Kaiser today and the rep there told me they have no preexisting condition clauses on group coverage policies.

Hmm...

[mykidslovedogs]

Originally Posted by Cute Fuzzy Bunny

Yeah Martha, you gave me the scoop already, but when I saw the $2600 bill, I started looking for ways to weasel out of it.

Interestingly, I called Kaiser today and the rep there told me they have no preexisting condition clauses on group coverage policies.

Hmm...

Cute and Fuzzy - I have always been told by Kaiser that they don't enforce the pre-ex, because they are an HMO, and since they have the ability to enforce open enrollment, they use open enrollment rules instead of pre-existing condition limitations to control adverse selection.

However, I wasn't sure if the rules were different between small and large group. For sure, in Colorado, Kaiser does not enforce pre-ex rules in the small group market. In fact, it is always Kaiser that we use for small groups and groups of one that have had a gap in coverage of longer than 90 days (the small group limit), because they don't care about gaps in coverage for new groups. I haven't had to deal with Kaiser in the large group market yet, and that's why I thought it best if you call them just to be sure.

I have also been told the same is true on the Blue HMO products, too.

[mykidslovedogs]

These are some rules in Colorado Statutes regarding pre-ex: Notice section III (In Colorado, Kaiser fits into section III - perhaps the rules are similar in your state)

10-16-118. Limitations on preexisting condition limitations.
Statute text
(1) A health coverage plan that covers residents of this state:

(a) (I) If it is a group health benefit plan, shall not deny, exclude, or limit benefits for a covered individual because of a preexisting condition for losses incurred more than six months following the date of enrollment of the individual in such plan or, if earlier, the first day of the waiting period for such enrollment; except that, for business groups of one, a health benefit plan shall not deny, exclude, or limit benefits for a covered individual because of a preexisting condition for losses incurred more than twelve months following the date of enrollment of the individual in such plan. A group health benefit plan may impose a preexisting condition exclusion or limitation only if such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within six months immediately preceding the date of enrollment of the individual in such plan or, if earlier, the first day of the waiting period for such enrollment; except that a group health benefit plan shall not impose any preexisting condition exclusion in the case of a child that is adopted or placed for adoption before attaining eighteen years of age, or relating to pregnancy.

(II) If it is an individual health benefit plan, or a group health coverage plan to which subparagraph (I) of this paragraph (a) does not apply, shall not deny, exclude, or limit benefits for a covered individual because of a preexisting condition for losses incurred more than twelve months following the effective date of coverage and may not define a preexisting condition more restrictively than an injury, sickness, or pregnancy for which a person incurred charges, received medical treatment, consulted a health care professional, or took prescription drugs within twelve months.

(III) If it is a health maintenance organization that does not utilize preexisting condition limitations in any health benefit plan, may impose an affiliation period. An affiliation period shall run concurrently with any waiting period. Such a health maintenance organization may, in lieu of an affiliation period, use an alternative method to address adverse selection with the prior approval of the commissioner.

(b) Shall waive any affiliation period or time period applicable to a preexisting condition exclusion or limitation period for the period of time an individual was previously covered by creditable coverage if such creditable coverage was continuous to a date not more than ninety days prior to the effective date of the new coverage. The period of continuous coverage shall not include any waiting period for the effective date of the new coverage. This paragraph (b) shall not preclude application of any waiting period applicable to all new enrollees under the plan. The method of crediting and certifying coverage shall be determined by the commissioner by rule.

[mykidslovedogs]

Here's an interesting link: notice page 56

http://www.opm.gov/insure/01/brochures/73-003.pdf

Looks like Kaiser may be pretty consistent in waiving the pre-existing condition limitation.


....And here is the link on Kaiser Foundation Health Plan of Colorado...notice page 6

http://www.opm.gov/insure/99/brochures/73-019.pdf

[Freein05]

Originally Posted by mykidslovedogs

Here's an interesting link: notice page 56

http://www.opm.gov/insure/01/brochures/73-003.pdf

Looks like Kaiser may be pretty consistent in waiving the pre-existing condition limitation.


....And here is the link on Kaiser Foundation Health Plan of Colorado...notice page 6

http://www.opm.gov/insure/99/brochures/73-019.pdf

If they waive it for one they will have to waive it for all to avoid charges of discrimination. Be sure to get the waiver in writing from Kaiser to be safe.