No coverage for kidney trasplant

[Cheryl Hagan]

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

My bosses wife is a type one diabetic and has had a kidney transplant 8 yrs ago yet needs another kidney transplant and we have not had insurance for a yr to cover a pre-existing surgery. We have done exhaustive research to find out what to do. What are our options?

 

[cbg]

Not all policies have a pre-ex clause.

It is unclear whether or not she is currently covered on an existing plan, but has not been on it for a year, OR if there is no coverage at all. Can you clarify? It makes a difference.

 

[Cheryl Hagan]

There is not any previous coverage within the 90 days it has been over 6 months. We own a small elevator company (4 employees) and had to pull out of the union in Jan and therefor lost benefits. We had an insurance broker tell us cigna would cover but found out from other brokers (the same day after we sent our monies to cigna) that they would not.

 

[cbg]

Okay, let me be certain I understand.

You have had a plan in place for 90 days. The employee or dependent in question is currently covered on that plan. Prior to that, there had been no coverage for six months.

Is that right?

 

[Cheryl Hagan]

Sorry I was not more clear it had been a hectic day and I was answering on the run via iPhone. We just signed up two weeks ago for January 1 2010 effective date. She is an employee as well as wife of the president. She enrolled as an employee to make sure we had enough employees to receive coverage. Our company is beginning to grow and health care is a benefit we would like to offer prospective employees. We feel health care is an important asset in attracting potentials to us as opposed to another independant company since union companies have so many on the bench

 

[ecmst12]

The company can get a policy without a pre-existing exclusion. It will probably cost more, and it may be too late now since it's already been enrolled in and will start in a few weeks now.

 

[moburkes]

Sorry I was not more clear it had been a hectic day and I was answering on the run via iPhone. We just signed up two weeks ago for January 1 2010 effective date. She is an employee as well as wife of the president. She enrolled as an employee to make sure we had enough employees to receive coverage. Our company is beginning to grow and health care is a benefit we would like to offer prospective employees. We feel health care is an important asset in attracting potentials to us as opposed to another independant company since union companies have so many on the bench

You're a man named Cheryl? Just asking.

 

[cbg]

Okay, I think I get it now.

You need to find out DIRECTLY FROM CIGNA, not your broker, very decidedly not from brokers that did not negotiate the policy, if there is a pre-ex clause in your policy. Not all policies have one. Not even all policies with the same carrier will have one. ONLY Cigna can tell you for certain.

If there is a pre-ex clause, then since this is an employer-sponsored group plan the following limits apply; Any condition for which she had been treated in the last six months, can be considered pre-existing for up to but not exceeding 12 months. IF the employee in question (it doesn't matter about other employees - this is looked at on an individual basis) had previous creditable coverage less than 63 days before January 1, 2010, then the length of time she was covered on that plan will be subtracted from the 12 months. For example, if she had previous creditable coverage that ended less than 63 days before January 1, and that coverage lasted for eight months, then CIGNA can only consider her condition pre-ex for four months.

Clear as mud? This can be confusing, so feel free to ask questions.

 

[lkc15507]

Love the last answer but add.....just because I'm a pain in the "you know where", self-funded ERISA plans may differ from that. Also, there are some surprising beasts out there that have foiled many a careful person (self funded, non erisa, opted out of hipaa etc etc. An employer plan can be more generous than those time frames listed by cbg. Ask 'em. (I mean your HR office, specific type of plan etc.).

 

[ecmst12]

Anyone can be more generous but even self funded plans can NOT consider anything pre-existing for more then 12 months and only in the circumstances described. Those are federal guidelines and can't be gotten around.

And we did mention that not all plans even HAVE pre-existing exclusion.

 

[lkc15507]

Jeez-O-Pete you annoy me. My whole point is that this person could have a shorter lookback, a shorter look forwaward or no pre -x at all depending upon his her / plan. Conversely, could have completely vice versa. Again, without knowing plan type etc., an answer is almost useless. You try explaining to the some 140 million folks in the US covered by self funded plans that OOPS I made a mistake, your situation doesn't apply to the norm. My comment about anyone being more generous is that Plans frequently are. Would you want this poster to short change their options based upon a usual situation? Especially when that situation is NOT necessarily the norm?

 

[ecmst12]

You didn't add anything. OP was already told that it would depend on the specific plan and the employer would have the choice what type of plan it was and what (if any) the exclusion would be. And since nothing was posted for a week and OP has not been back, those answers were obviously enough for him to go back to HR and figure it out. Your habit of waking up dead threads to post stuff that was already said annoys ME. At least have something NEW and USEFUL to add if you have to post in something more then 3 days dormant.

 

[cbg]

Hey, ladies, you know I love and respect you both, but how about you take it outside? The rest of us don't need to hear this.

BTW, I didn't mention that self-insured plans can be different because the chances of a plan this small being self-funded are pretty small. Face it, if a group this tiny is self-funded and immediately facing a potential transplant, they've got bigger problems than pre-ex.

On the other hand, if the plan is self-funded, all they have to do is tell the administrator to pay it.