Healthcare - Private/Employer Pregnancy

[BHAussie]

What is the name of your state (only U.S. law)? CA

Howdy,

Can an individual with a private insurance policy that contains provision for pregnancy, where the policy holder is not currently pregnant, switch to a new policy, in this case to an employer group policy (large corporate plan), without losing immediate coverage for pregnancy, i.e. not to require to have a waiting period of e.g. 6 months to a year before becoming pregnant?

Cheers

 

[cbg]

With extremely limited exceptions, Federal law, which applies in all states including California (despite attempts on the part of the state of CA to appear that it is otherwise) employer-sponsored group plans may not consider pregnancy a pre-existing condition.

Frequently Asked Questions about Portability of Health Coverage and HIPAA

 

[BHAussie]

Thankyou "cbg" very much for your reply as I respect your answers.

I read the faq page and just to completely clarify please (as some changes will be made to current insurance cover):

1. even if the individual is pregnant they could still apply and must be covered (without a waiting period)?
2. if they're not pregnant they can apply and be covered immediately?
3. the nexus for determining location is the place of actual employment (i.e. not a head office out of state)?

I guess if they try to say anything different I'll suggest their policy is in conflict with the HIPAA...

Thanks again - hope to be saving some cash.

 

[cbg]

Okay, let me try again.

There are NO circumstances where a qualifying employee can be turned down for employer-sponsored group insurance. None. No matter what medical condition they have. If you meet the definition of a covered employee under the plan document, you CANNOT be turned down. And the definition of a covered employee CANNOT limit you on the basis of any medical condition.

It would violate more than one Federal law to have a waiting period only for pregnancy. Being pregnant does not mean they have to waive any waiting period that all other employees are subject to, but there cannot be a waiting period after you are covered before they will cover pregnancy.

The laws for what must be covered are based on your location and not that of the head office; however, the laws I am referring to are Federal laws and apply in all 50 states.

Do you have a reason for believing that they will try to deny coverage? Any employer and/or insurance carrier with a brain cell and a half would know that the kind of restrictions you are talking about are illegal.

 

[ecmst12]

IMO, the days of individual policies being allowed to impose a waiting period before covering pregnancy are coming to an end as well...

 

[BHAussie]

Thanks cbg again - just that when something seems too good to be true, you want to make sure kinda thing...

Also with plans that are not employer sponsored (individual), there is a waiting period so I thought the same would apply.

Nice to have a win for a change.

Sorry, but I do have one more query, can they specify that there is an "annual open enrollment period" as the only time to sign-up under the employer program (apart from a life incident like a birth, marriage or within 31 days of employment or change of status p/t to f/t)? Their plan also states that coverage would not apply until the following April 1st (in this case).

PS ecmst12 - I hear you re. individual policies, but the new legislation covering pre-exisitng conditions that may include pregnancy I believe unfortunately doesn't kick in until 2014 (presently for children with pre-existing conditions only under the new law - republicans want to repeal lol).

 

[pattytx]

Yes, they can. However, they must allow you to enroll if there is a "qualifying event". For example, becoming covered under your spouse's plan, then becoming ineligible for that plan (say, if your spouse lost his job or had his hours cut) would be a qualifying event. Being a new employee to the company would obviously be a qualifying event. Merely deciding now that you want to change from your individual policy to the group plan (when you did not elect it either at hire or during the last open enrollment period) is not a qualifying event; "buyer's remorse" is not a qualifying event. My understanding is that you have 31 days following the qualifying event to enroll; if you don't, then yes, you would have to wait until the next open enrollment period.

 

[cbg]

They not only can, they must.

Federal law limits the times under which an employer can allow an employee to make changes to their employer sponsored health insurance plan, due to the pre-tax nature of the premiums. Only during a "qualifying event" as defined by IRS regs and/or the insurance plan document can a change be made (including adding or deleting dependents or making a change to the plan itself) outside of the annual open enrollment.

Marriage, divorce, birth, death, adoption, a change of job, a spouse gaining/losing coverage, are pretty much universally considered qualifying events. Some employers may have other specifications; for example, I work for a major university where we have people coming in and going out of the country while they do research. Their family may or may not come with them at the same time. So our plan document allows that entry/leaving the country is a qualifying event. Our semi-sister university down the road (we're an entirely different institution but we share some research projects) does the same thing - I worked for them a couple of years ago.

So not only is your employer not violating any laws, they are in fact required by law to do it that way.

 

[BHAussie]

Thank you both for your replies. I'll be confirming the starting date for the next period.

My 2 cents: IMO, the law is overly restrictive regarding open enrollment periods and qualifying events, pertaining, as cbg mentioned, to calculations for taxation purposes (considering this modern age of computing there must be a way for administering any tax provisions somehow I'm sure) as it restricts freedom of choice - if I want an individual plan today tomorrow or any other day, I can...

Request: Universal Healthcare...please?

Cheers guys

 

[pattytx]

It is what it is. Until it isn't.

 

[Zigner]

Request: Universal Healthcare...please?

Yeah, that'll work great. Just ask our friends up north and across the pond

 

[ecmst12]

The VAST, vast majority of whom are extremely happy with their universal healthcare.