Pre Existing condition and new insurance

[SeanH529]

Just wondering if anyone has any info they can share with me about this. I will be changing insurance from Atena to Blue Cross Blue Shield of Alabama. Does anyone know if they cover Enbrel for PA? Is it a $20 co pay? and do you think they might hit me with the old "pre existing condition?" Anyone who can help me out with info, I appreciate it!

[khorath]

I don't know much about Blue Cross/Blue Shield, but if your previous insurance company give you a certificate of prior coverage (which they are legally obligated to do), there should be no "pre-existing condition" issues.

I do not know how BC/BS covers Enbrel. That part is not mandated by law (at least as far as I know).

[SeanH529]

I have a month until this new insurance kicks in and a months supply sitting in my fridge, should I call my old insurance and ask for a certificate? or would I be able to get it at my old pharmacy?

[jeffxc]

I think you may want to review your policy, looking for their procedures on pre-existing conditions. When we changed insurance policies (many years ago), the new insurance company had a waiting period before they would cover any (pre-existing conditions), or had a clause that stated you would be covered only if you hadn't been treated for that condition for 6 months (I understand that it's now a year).

Please look before you leap.

[chaimFL]

Unfortunately insurance is not regulated as interstate commerce so there for each state is different. In Florida I think they give you 30 or 60 days from the ending of one policy to the start of the new one before they deny coverage because of preexisting condition. If you want you can get a letter, but they may not give it to you until the policy has actually lapsed because the letter only needs to state that you were covered with insurance until whatever date the policy ended. The best idea would be to call BC/BS and ask what the guidlines are to make sure you are covered (tell them you are switching) and you can also ask them how they cover enbrel, but they might not beable to tell you unless you know exactly what policy you are getting and it may be different if it is a group policy or an individual policy.

[khorath]

The certificate should come from your insurance company. By law, I believe they must sent it to you within 14 days after your coverage ends. I also found this following information - this is a Federal Law regarding pre-existing conditions:

Coverage When You're Already Sick
The driving force behind HIPAA is that health insurance companies have traditionally tried to hold down their costs by invoking a "pre-existing condition" clause — refusing to cover a condition you had before you bought the health plan.

The concept of pre-existing conditions makes sense when you're talking about auto insurance: For example, if your windshield was cracked before you bought your coverage, you can't expect your new auto insurer to replace it after you buy a policy. That would be like asking your insurer to replace the windshield for free when you haven't paid premiums for that problem.

But when it comes to someone's health, the issue might seem less clear-cut or even downright unfair.

Got diabetes? Your current health plan might pay for insulin and visits to the doctor. But before HIPAA was enacted, if you switched to a new health plan, it would have been allowed to consider your diabetes a pre-existing condition and refuse to cover treatment for it. You'd then be stuck paying for all of your diabetes treatment yourself, on top of the regular out-of-pocket expenses you'd pay for other medical care. The frightening prospect of having to pay hundreds or thousands of dollars for your medical care is what created job lock and helped fuel the push for legislation banning such practices.

HIPAA imposes limits on the extent to which some health plans can exclude coverage for pre-existing conditions. For instance, if you've had "creditable" health insurance for 12 straight months, with no lapse in coverage of 63 days or more, and you switch to a new group health plan, it cannot invoke the pre-existing condition exclusion at all. It must cover your medical problems as soon as you enroll in the plan. (Newborns and adopted children who are covered within 30 days are not subject to the 12-month waiting period.)

Most health coverage is creditable. It includes prior coverage under a group health plan (including a governmental or church plan), health insurance coverage (either group or individual), Medicare, Medicaid, a military-sponsored health care program such as CHAMPUS, a program of the Indian Health Service, a state high-risk pool, the federal Employees Health Benefit Program, a public health plan established or maintained by a state or local government, and a health benefit plan provided for Peace Corps members.

On the other hand, if you don't have that creditable coverage behind you when you enroll in a new group plan, it can refuse to pay for any of your existing medical problems, but only for a maximum of 12 months. Late enrollees in group health plans may have to wait up to 18 months for coverage of pre-existing conditions.

[SeanH529]

well that makes me feel better. I had Aetna for over 1 year, and Enbrel was covered! I will keep everyone up to date on how this insurance switch is handled, because I think it's important we know what we are getting into. I'm 22 years old and am always looking for a better job right out of college, so I know this won't be the last time I'm going to have to deal with this.

[SeanH529]

Hey guys, here is an update on my insurance switch. SMALL update. My letter from my old company came in and I have it in my room. I just got a letter from BC/BS and they said I will have a pre existing condition and if I have documentation of credible insurance I need to send it to them. So I making a copy of their letter, and my insurance coverage and sending it in today. Once I get my next reply I'll let you know how the med is actually covered.