Quick insurance Question

August 15, 2007

Hi All,

I know the group has discussed this issue to death, so I tried to do

a search of past posts, but found too many emails that included the

word " insurance " . Sorry, but here's my question:

I've been told that with PSC you need to always have health

insurance - no brainer, but if one were to change jobs and forfit

their health insurance, isn't it always a option to just go on your

spouse's insurance if that's an option? And then if you (the PSCer)

changed jobs again, wouldn't a new employer's heath insurance cover

you? This is how it's always been with my wife and me - before I got

PSC. I assume it will continue like this and that the pre-existing

condition clause is normally limited to when you try to buy a

policy. We've checked with my wife's plan and there isn't a problem

like this for me now.

I only ask because it seems like people recommend greatly against

changing jobs if you loose your insurance.

Thanks,

Washington, DC

August 15, 2007

,

Many insurances will not cover pre existing diseases. When I was

first diagnosed with PSC I was only with my current employer for a

year. The insurance company wanted to know who my doctor was to check

to see if I was previously diagnosed. I wasn't so I was okay. But you

would need to check to if the new insurance company would cover you.

PSC 1989, TX1 97 tx2 04

And then if you (the PSCer)

> changed jobs again, wouldn't a new employer's heath insurance cover

> you? >

> Thanks,

>

> Washington, DC

>

August 15, 2007

Under HIPAA (passed ~1992), insurance companies are not allowed to

deny you coverage for pre-existing conditions as long as you've

maintained a qualifying insurance plan - in other words they can only

deny you based on pre-existing condition if you have one of the

dreaded insurance " gaps. " I know this and the various methods for

avoiding it (spouse's insurance, COBRA, etc.) have definitely been

discussed on this site before, I would search the posts for " pre-

existing " to find the detailed answers. tx,

Nina in Philly

,

> Many insurances will not cover pre existing diseases.

August 16, 2007

,

I'd like to know more about ths insurance issue and PSC. I don't understand, if you have a pre-existing condition, then it seems to me if you change jobs and that requires you to also change your insurance company, couldn't you simply pay a higher premimium but still be insured?

It seems absurd that one cannot change insurance companies or policies.

I'd appreciate hearing from the group on their experiences and this issue as it is a very touchy one anywhere, but especially in the States.

Ellen

> Many insurances will not cover pre existing diseases. When I was > first diagnosed with PSC I was only with my current employer for a > year. The insurance company wanted to know who my doctor was to check > to see if I was previously diagnosed. I wasn't so I was okay. But you > would need to check to if the new insurance company would cover you.> > PSC 1989, TX1 97 tx2 04> > And then if you (the PSCer) > > changed jobs again, wouldn't a new employer's heath insurance cover > > you? > > > Thanks,> > > > > > Washington, DC> >>

August 16, 2007

It all depends on the insurance company, and what the results of the contract negotiation with the employer were. There are also laws in some states that limit what can and cannot be done (Minnesota is considered to be quite liberal - there are many laws on insurance). Usually, the employer's benefit package includes a contract with a specific insurance company (or maybe a few selections). That contract is only with the employer and typically cannot be transferred.

In my case, when I started with this company 30 years ago, I wasn’t' aware of pre-existing condition limitations (I had just been diagnosed with UC). The only question I got was from the company nurse, who asked how I was doing. I doubt if I'd get the same treatment now. Most companies these days are not " one big family " any more and are driven by competition. When I retire, I will be required to change insurance, but I cannot be refused insurance. It will be much more expensive. 20 years ago, insurance was part of your retirement benefits. That is not the case any more, at least for us.

Arne

56 - UC 1977, PSC 2000

Alive and (mostly) well in Minnesota

________________________________

From: [mailto: ] On Behalf Of e_boermeester

,

I'd like to know more about ths insurance issue and PSC. I don't understand, if you have a pre-existing condition, then it seems to me if you change jobs and that requires you to also change your insurance company, couldn't you simply pay a higher premimium but still be insured?

It seems absurd that one cannot change insurance companies or policies.

August 17, 2007

Here's a pretty good summary of HIPAA law. It does not include the recently added privacy provisions and is written as a guideline for employer compliance. Sorry its long. Darcy HIPAA: THE NEW HEALTH INSURANCE REFORM LAW'S EFFECT ON EMPLOYER GROUP HEALTH PLANS By Berg Brigham On Aug. 21, 1996, President Clinton signed into law the Health Insurance Portability and Accountability Act ("HIPAA"). While the reforms included in this new law are not on the broad scale President Clinton favored early in his administration, the changes are

significant and compliance requires, among other things, tracking of employees’ and dependents’ coverage periods and benefits; review of existing health plans for any required changes; notification of COBRA qualified beneficiaries regarding changes; revision of benefits communications; and preparation of new forms. This article examines the rationale and provisions of HIPAA as they affect employer group health plans. It also references key provisions and includes model forms from the interim final regulations issued by the Departments of Labor, Treasury, and Health and Human Services in April 1997. The central elements of HIPAA are its portability provisions. These reforms are designed to help employees who change or lose jobs to maintain health coverage by requiring subsequent employers to accept them into health plans. To achieve this the law: • prohibits group health plans from

establishing eligibility rules based on health status; • limits the duration and extent to which group health plans may exclude preexisting conditions; • requires group health plans to track and provide certification of an individual’s coverage when the individual leaves the plan so that he or she may gain access to another plan with reduced or no preexisting condition limitations; • requires special enrollment periods for individuals losing other coverage under certain circumstances; • clarifies and extends COBRA; and • expands ERISA’s disclosure requirements. In addition, the health insurance reform law includes provisions specifically aimed at helping small businesses and self-employed individuals obtain and retain health coverage.

These provisions include guaranteed availability of coverage for small groups; guaranteed renewability of existing coverage; tax-favored medical savings accounts to cover out-of-pocket expenses in conjunction with high-deductible insurance; and increased tax deductibility for health premiums paid by self-employed individuals. Limits on Health-Related Exclusions While the new health insurance reform law does not dictate specific benefits or levels of coverage, it forbids exclusions based upon health status and limits the imposition of preexisting condition exclusions. Group health plans may not exclude employees or dependents (if otherwise covered under the plan) based on health status, medical condition (physical or mental), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic

violence), or disability. Moreover, HIPAA prohibits plans from requiring higher premium contributions based on an individual’s or dependent’s health status. The new law does not, however, preclude premium discounts or rebates in connection with bona fide health promotion and wellness programs. The interim regulations do not provide much guidance in this area and leave open the issue whether discounts to non-smokers would be permitted. Preexisting condition limitations are closely circumscribed by HIPAA. A health plan may impose a preexisting condition exclusion only if it relates to a condition for which care was recommended or received within the six months preceding enrollment in the plan and applies for no more than 12 months (18 months in the case of a late enrollee). The duration of any exclusion is further reduced by the length of "creditable coverage" the employee had previously (i.e., health coverage with no break longer than

63 days, excluding the plan’s own waiting period). Certain conditions and beneficiaries may not be subject to preexisting condition exclusions. Under no circumstances may pregnancy be treated as a preexisting condition. In addition, no preexisting condition exclusions may be applied to newborns or adopted children who have any creditable coverage within the first thirty days following birth or adoption. And absent a diagnosis of a related condition, genetic information may not be treated as a preexisting condition. Employers must inform all group health plan participants of the existence and terms of any preexisting condition exclusions in writing and also must advise them that the exclusion period may be reduced by their creditable coverage. When imposing a preexisting condition exclusion, the plan must notify the participant. This notice must include the source and substance of any information

upon which the plan relied in making its determination, as well as the plan’s appeals procedures. A determination that an individual has a preexisting condition generally would be made through medical records (e.g., diagnosis codes on bills, physicians’ notes, prescription records) during the six-month "look-back" period before enrollment. In making such a determination, a plan may not use the "prudent person" standard followed in some states whereby a condition may be taken into account if a prudent person would have sought care, regardless of whether any care was received. Moreover, a plan may not exclude coverage for any condition identified during a physical examination conducted during the waiting period (after employment begins and before enrollment) unless treatment of the condition was recommended or received during the six-month look-back period. Any waiting period imposed by the plan

must run concurrently with the preexisting condition exclusion period and does not count as a break in coverage. But the days in a waiting period do not count as "creditable coverage" either. Health Maintenance Organizations (HMOs) may use "affiliation periods" of two months (three months for late enrollees) in lieu of preexisting condition exclusions. The affiliation period begins with enrollment in the plan and may not be repeated if the employer changes plans. Certification of Coverage Beginning June 1, 1997, group health plans must automatically issue "certificates of coverage" to employees and dependents when they are no longer covered by the plan or after their COBRA coverage ceases. These automatic certificates need only reflect the most recent period of continuous coverage. In addition, group health plans must provide these certificates at an individual’s request for up to 24

months after coverage under the plan or COBRA ends. Such requested certificates should indicate all periods of continuous coverage ending within the 24 months prior to the date of the request. Fortunately, the interim regulations include a model "Certificate of Group Health Plan Coverage" that is fairly user friendly. If an individual has at least 18 months of creditable coverage, the plan administrator need only indicate that fact, as well as the date coverage ended (or that it is continuing) on the certificate. Otherwise, the certificate must also include the date any waiting or affiliation period began and the date coverage began. Separate certificates must be provided for the plan participant and each beneficiary if the information is not identical for these individuals. This may be difficult for employers whose data systems are not set up to track dependent coverage. In recognition of

this problem, the interim regulations include the following transition rule: through June 30, 1998, a plan may satisfy its certification obligation regarding a dependent by providing the name of the covered plan participant and specifying the type of coverage provided (e.g., family coverage, employee-plus-spouse coverage). But if requested to provide a certificate for a dependent, the plan must make reasonable efforts to obtain and provide the name of the dependent. After June 30, 1998, plans will have to make reasonable efforts to collect dependent information and include it on the certificate. An automatic certificate based upon a dependent’s loss of coverage is not required until the plan knows or, making reasonable efforts, should know of the loss of coverage. The interim regulations suggest that this information be collected annually during open enrollment. Individuals who are entitled to an automatic certificate because of loss

of coverage must be provided with the certificate within the same time frame as notice of a qualifying event under COBRA. Where the certificate is provided upon the request of an individual within 24 months of the loss of coverage, the certificate must be provided at the earliest time that the plan, acting in a reasonable and prompt fashion, can do so. Plans and insurers or third party administrators may decide among themselves which party will be responsible for providing the certificates of coverage and other notices required by HIPAA. Such agreements should be put into writing. The certificate may be mailed to the participant’s last known address. In addition, coverage information may be provided by telephone if all parties agree. If a participant entering a plan has not received a certificate of coverage from his or her previous plan, the new plan must consider whatever other documentation the participant can provide (e.g., pay

stubs reflecting deductions for health insurance, explanation of benefits forms) in determining the participant’s creditable coverage. Although a group health plan need not issue the certifications before June 1, 1997, the tracking of coverage must include all periods of coverage from July 1, 1996, forward. For the period between July 1, 1996 and Oct. 1, 1996, a plan will be required to provide certification only upon an individual’s written request. For the period between October 1, 1996, and May 31, 1997, the interim regulations provide a transition rule whereby employers may issue special notices to plan participants losing coverage during that time in lieu of providing certificates of coverage. This will be particularly helpful for employers with a large number of employees who lost coverage during that period, because the actual coverage periods will have to be determined only for participants requesting certificates. The interim

regulations include a Model Notice for this purpose. Crediting Coverage For New Entrants Into Plan The corollary to the certification of coverage by the prior plan is the crediting of coverage by the "new" plan against any preexisting condition exclusion imposed under the plan. The prior coverage may include another group health plan, health insurance coverage, Medicare, Medicaid, CHAMPUS, state risk pools, or the Federal Employee Health Benefits Plan. A period of coverage need not be credited if there was a gap of 63 days or more between that period of coverage and the individual’s enrollment in the group health plan. In crediting the prior coverage, any preexisting condition exclusion applied under the plan generally must be offset by all days of a new entrant’s creditable coverage, regardless of the specific benefits provided in the period

of creditable coverage. Alternatively, an employer may elect to credit coverage separately with respect to five specific categories of coverage: mental health, substance abuse treatment, prescription drugs, dental care, and vision care. This election must be made on a uniform basis for all participants and beneficiaries. The plan may use this alternative method for any or all of these categories of coverage and may apply a different preexisting condition exclusion period with respect to each category. The standard "day-for-day" method still must be used to determine an individual’s creditable coverage for benefits not within any category for which the alternative method is used. The plan’s disclosure statements, including plan information provided at the time of enrollment, must prominently indicate that the alternative method is being used and describe the effect of using the alternative method (i.e., that certain benefits may be subject to preexisting condition

exclusions if not included in the prior coverage). Because some plans will adopt this alternative method for crediting prior coverage, group health plans will also be required to disclose to other plans information regarding the five categories of health benefits so that the subsequent group health plan or insurer may evaluate it for purposes of crediting the coverage. A plan may charge the reasonable cost of disclosing such information. Certain benefits, including separate vision or dental policies, disease-specific coverage, and Medicare supplemental coverage, are excluded from HIPAA’s portability provisions. Special Enrollment Periods Group health plans must allow special enrollment periods for employees and dependents who previously declined coverage under the plan because of other coverage. This 30-day

enrollment period applies only if the employee and/or dependent lost coverage because of exhaustion of COBRA benefits, for "COBRA-like" reasons (i.e., separation, divorce, death, termination of employment, reduction of hours), or if the employer contributions to the other coverage were terminated. Plans that cover dependents must also provide a 30-day enrollment period for individuals who become dependents by marriage, birth, adoption, or placement for adoption. An employee’s spouse may also enroll as a dependent under the employee’s coverage at the time of birth or adoption of a child. A special enrollee is not treated as a late enrollee, and thus the maximum applicable preexisting condition limitation period is 12 months less any creditable coverage. Pursuant to the interim regulations, plans must provide a description of these special enrollment rights to anyone declining coverage. The regulations include a Model Description. .

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August 20, 2007

Thanks for this great information!

Berry

Washignton, DC

>

> Here's a pretty good summary of HIPAA law. It does not include

the recently added privacy provisions and is written as a guideline

for employer compliance. Sorry its long.

>

> Darcy

>

> HIPAA: THE NEW HEALTH INSURANCE REFORM LAW'S EFFECT ON EMPLOYER

GROUP HEALTH PLANS

> By Berg Brigham

>

> On Aug. 21, 1996, President Clinton signed into law the Health

Insurance Portability and Accountability Act ( " HIPAA " ). While the

reforms included in this new law are not on the broad scale

President Clinton favored early in his administration, the changes

are significant and compliance requires, among other things,

tracking of employees' and dependents' coverage periods and

benefits; review of existing health plans for any required changes;

notification of COBRA qualified beneficiaries regarding changes;

revision of benefits communications; and preparation of new forms.

This article examines the rationale and provisions of HIPAA as they

affect employer group health plans. It also references key

provisions and includes model forms from the interim final

regulations issued by the Departments of Labor, Treasury, and Health

and Human Services in April 1997.

> The central elements of HIPAA are its portability provisions.

These reforms are designed to help employees who change or lose jobs

to maintain health coverage by requiring subsequent employers to

accept them into health plans. To achieve this the law:

> • prohibits group health plans from establishing eligibility

rules based on health status;

> • limits the duration and extent to which group health plans may

exclude preexisting conditions;

> • requires group health plans to track and provide certification

of an individual's coverage when the individual leaves the plan so

that he or she may gain access to another plan with reduced or no

preexisting condition limitations;

> • requires special enrollment periods for individuals losing

other coverage under certain circumstances;

> • clarifies and extends COBRA; and

> • expands ERISA's disclosure requirements.

>

> In addition, the health insurance reform law includes provisions

specifically aimed at helping small businesses and self-employed

individuals obtain and retain health coverage. These provisions

include guaranteed availability of coverage for small groups;

guaranteed renewability of existing coverage; tax-favored medical

savings accounts to cover out-of-pocket expenses in conjunction with

high-deductible insurance; and increased tax deductibility for

health premiums paid by self-employed individuals.

> Limits on Health-Related Exclusions

> While the new health insurance reform law does not dictate

specific benefits or levels of coverage, it forbids exclusions based

upon health status and limits the imposition of preexisting

condition exclusions. Group health plans may not exclude employees

or dependents (if otherwise covered under the plan) based on health

status, medical condition (physical or mental), claims experience,

receipt of health care, medical history, genetic information,

evidence of insurability (including conditions arising out of acts

of domestic violence), or disability. Moreover, HIPAA prohibits

plans from requiring higher premium contributions based on an

individual's or dependent's health status. The new law does not,

however, preclude premium discounts or rebates in connection with

bona fide health promotion and wellness programs. The interim

regulations do not provide much guidance in this area and leave open

the issue whether discounts to non-smokers would be permitted.

> Preexisting condition limitations are closely circumscribed by

HIPAA. A health plan may impose a preexisting condition exclusion

only if it relates to a condition for which care was recommended or

received within the six months preceding enrollment in the plan and

applies for no more than 12 months (18 months in the case of a late

enrollee). The duration of any exclusion is further reduced by the

length of " creditable coverage " the employee had previously (i.e.,

health coverage with no break longer than 63 days, excluding the

plan's own waiting period).

> Certain conditions and beneficiaries may not be subject to

preexisting condition exclusions. Under no circumstances may

pregnancy be treated as a preexisting condition. In addition, no

preexisting condition exclusions may be applied to newborns or

adopted children who have any creditable coverage within the first

thirty days following birth or adoption. And absent a diagnosis of a

related condition, genetic information may not be treated as a

preexisting condition.

> Employers must inform all group health plan participants of the

existence and terms of any preexisting condition exclusions in

writing and also must advise them that the exclusion period may be

reduced by their creditable coverage. When imposing a preexisting

condition exclusion, the plan must notify the participant. This

notice must include the source and substance of any information upon

which the plan relied in making its determination, as well as the

plan's appeals procedures.

> A determination that an individual has a preexisting condition

generally would be made through medical records (e.g., diagnosis

codes on bills, physicians' notes, prescription records) during the

six-month " look-back " period before enrollment. In making such a

determination, a plan may not use the " prudent person " standard

followed in some states whereby a condition may be taken into

account if a prudent person would have sought care, regardless of

whether any care was received. Moreover, a plan may not exclude

coverage for any condition identified during a physical examination

conducted during the waiting period (after employment begins and

before enrollment) unless treatment of the condition was recommended

or received during the six-month look-back period.

> Any waiting period imposed by the plan must run concurrently

with the preexisting condition exclusion period and does not count

as a break in coverage. But the days in a waiting period do not

count as " creditable coverage " either. Health Maintenance

Organizations (HMOs) may use " affiliation periods " of two months

(three months for late enrollees) in lieu of preexisting condition

exclusions. The affiliation period begins with enrollment in the

plan and may not be repeated if the employer changes plans.

> Certification of Coverage

> Beginning June 1, 1997, group health plans must automatically

issue " certificates of coverage " to employees and dependents when

they are no longer covered by the plan or after their COBRA coverage

ceases. These automatic certificates need only reflect the most

recent period of continuous coverage. In addition, group health

plans must provide these certificates at an individual's request for

up to 24 months after coverage under the plan or COBRA ends. Such

requested certificates should indicate all periods of continuous

coverage ending within the 24 months prior to the date of the

request.

> Fortunately, the interim regulations include a

model " Certificate of Group Health Plan Coverage " that is fairly

user friendly. If an individual has at least 18 months of creditable

coverage, the plan administrator need only indicate that fact, as

well as the date coverage ended (or that it is continuing) on the

certificate. Otherwise, the certificate must also include the date

any waiting or affiliation period began and the date coverage began.

> Separate certificates must be provided for the plan participant

and each beneficiary if the information is not identical for these

individuals. This may be difficult for employers whose data systems

are not set up to track dependent coverage. In recognition of this

problem, the interim regulations include the following transition

rule: through June 30, 1998, a plan may satisfy its certification

obligation regarding a dependent by providing the name of the

covered plan participant and specifying the type of coverage

provided (e.g., family coverage, employee-plus-spouse coverage). But

if requested to provide a certificate for a dependent, the plan must

make reasonable efforts to obtain and provide the name of the

dependent. After June 30, 1998, plans will have to make reasonable

efforts to collect dependent information and include it on the

certificate. An automatic certificate based upon a dependent's loss

of coverage is not required until the plan knows or, making

> reasonable efforts, should know of the loss of coverage. The

interim regulations suggest that this information be collected

annually during open enrollment.

> Individuals who are entitled to an automatic certificate because

of loss of coverage must be provided with the certificate within the

same time frame as notice of a qualifying event under COBRA. Where

the certificate is provided upon the request of an individual within

24 months of the loss of coverage, the certificate must be provided

at the earliest time that the plan, acting in a reasonable and

prompt fashion, can do so. Plans and insurers or third party

administrators may decide among themselves which party will be

responsible for providing the certificates of coverage and other

notices required by HIPAA. Such agreements should be put into

writing.

> The certificate may be mailed to the participant's last known

address. In addition, coverage information may be provided by

telephone if all parties agree. If a participant entering a plan has

not received a certificate of coverage from his or her previous

plan, the new plan must consider whatever other documentation the

participant can provide (e.g., pay stubs reflecting deductions for

health insurance, explanation of benefits forms) in determining the

participant's creditable coverage.

> Although a group health plan need not issue the certifications

before June 1, 1997, the tracking of coverage must include all

periods of coverage from July 1, 1996, forward. For the period

between July 1, 1996 and Oct. 1, 1996, a plan will be required to

provide certification only upon an individual's written request. For

the period between October 1, 1996, and May 31, 1997, the interim

regulations provide a transition rule whereby employers may issue

special notices to plan participants losing coverage during that

time in lieu of providing certificates of coverage. This will be

particularly helpful for employers with a large number of employees

who lost coverage during that period, because the actual coverage

periods will have to be determined only for participants requesting

certificates. The interim regulations include a Model Notice for

this purpose.

> Crediting Coverage For New Entrants Into Plan

> The corollary to the certification of coverage by the prior plan

is the crediting of coverage by the " new " plan against any

preexisting condition exclusion imposed under the plan. The prior

coverage may include another group health plan, health insurance

coverage, Medicare, Medicaid, CHAMPUS, state risk pools, or the

Federal Employee Health Benefits Plan. A period of coverage need not

be credited if there was a gap of 63 days or more between that

period of coverage and the individual's enrollment in the group

health plan.

> In crediting the prior coverage, any preexisting condition

exclusion applied under the plan generally must be offset by all

days of a new entrant's creditable coverage, regardless of the

specific benefits provided in the period of creditable coverage.

Alternatively, an employer may elect to credit coverage separately

with respect to five specific categories of coverage: mental health,

substance abuse treatment, prescription drugs, dental care, and

vision care. This election must be made on a uniform basis for all

participants and beneficiaries. The plan may use this alternative

method for any or all of these categories of coverage and may apply

a different preexisting condition exclusion period with respect to

each category. The standard " day-for-day " method still must be used

to determine an individual's creditable coverage for benefits not

within any category for which the alternative method is used. The

plan's disclosure statements, including plan information provided

> at the time of enrollment, must prominently indicate that the

alternative method is being used and describe the effect of using

the alternative method (i.e., that certain benefits may be subject

to preexisting condition exclusions if not included in the prior

coverage).

> Because some plans will adopt this alternative method for

crediting prior coverage, group health plans will also be required

to disclose to other plans information regarding the five categories

of health benefits so that the subsequent group health plan or

insurer may evaluate it for purposes of crediting the coverage. A

plan may charge the reasonable cost of disclosing such information.

> Certain benefits, including separate vision or dental policies,

disease-specific coverage, and Medicare supplemental coverage, are

excluded from HIPAA's portability provisions.

> Special Enrollment Periods

> Group health plans must allow special enrollment periods for

employees and dependents who previously declined coverage under the

plan because of other coverage. This 30-day enrollment period

applies only if the employee and/or dependent lost coverage because

of exhaustion of COBRA benefits, for " COBRA-like " reasons (i.e.,

separation, divorce, death, termination of employment, reduction of

hours), or if the employer contributions to the other coverage were

terminated. Plans that cover dependents must also provide a 30-day

enrollment period for individuals who become dependents by marriage,

birth, adoption, or placement for adoption. An employee's spouse may

also enroll as a dependent under the employee's coverage at the time

of birth or adoption of a child. A special enrollee is not treated

as a late enrollee, and thus the maximum applicable preexisting

condition limitation period is 12 months less any creditable

coverage. Pursuant to the interim regulations, plans must

> provide a description of these special enrollment rights to

anyone declining coverage. The regulations include a Model

Description.

>

> .

>

> ---------------------------------

> Got a little couch potato?

> Check out fun summer activities for kids.

>

August 20, 2007