I want to add my wife who has serious pre-existing conditions to my health insurance plan at work. How do we make sure her condition will be covered?

March 31, 2009 2:24 PM

I want to add my wife who has serious pre-existing conditions to my health insurance plan at work. How do we make sure her condition will be covered?

My wife needs orthognathic surgery but her insurance (HMO) will only cover a portion of it under a doctor she does not trust and will not address all symptoms involved. I have a much better plan at my work, but have noticed that when adding someone to the plan, there is a waiting period of 6 months for anyone with pre-existing conditions before they will start to cover them.

My wife is in constant pain everyday and doesn't think she can wait any longer, nor do the doctors she would like to be treated by, as her condition gets worse everyday. My first question then, is there anything that can be done to shorten the waiting period?

If we must wait the 6 months before she can get the surgery, so be it. It's too costly to even attempt to pay it out of pocket right now, but we absolutely can't have her go without medication and physical therapy to help relieve the everyday pain. But on the new plan, would these treatments be considered part of the "pre existing" condition?
Is it possible for her to keep her current plan just for these things WHILE she is on the waiting period for my plan?

Also, in terms of other things that would not be covered due to the pre-existing mess, would these things also include consultations with surgeons? MRI's? any testing she would need for the eventual treatment she would receive after the 6 months is up?
Or are these "tests" going to be excluded as well even though they are just tests and not actual treatment?

posted by anonymous to health & fitness (4 comments total)

Is the 6 month period in effect even if the new addition comes under the plan with credible coverage? That seems unusual. Typically, pre-existing clauses are for people who come into the plan without credible coverage letters.
posted by hworth at 2:28 PM on March 31

Check for a credible coverage exemption. If your wife has no break in coverage (or a short one, it depends on your insurance's rules) they might waive the waiting period. You just need to provide proof of her past insurance coverage, usually that comes in the form of a letter from her former insurance.
posted by DrGirlfriend at 2:45 PM on March 31

Every insurance plan is different, and some states have different rules regarding pre-existing conditions. But...

- The letter from her former insurance company is typically called a HIPPA letter. You should be able to call them to have them send it to you.

- Your current HR representative may be very helpful in answering your questions, or at least direct you to someone who can help.
posted by ShooBoo at 3:24 PM on March 31

I was in roughly the same situation. Because I had maintained continuous coverage through COBRA and private insurance, coverage for my orthognathic treatment under my husband's plan (BCBS) was a nonissue. So, nthing what others have said about checking with your specific plan.

That said, orthognathic surgery, if she has not begun the treatment process yet, is unlikely to occur in less than 6 months anyhow.

She should consult with a good orthodontist who works in conjunction with an oromaxillofacial surgeon, perhaps even in the same practice. The orthodontist is responsible for positioning the teeth before the surgery to accommodate the surgeon's needs, and after the surgery to perfect the bite and teeth alignment. In addition, orthodontic hardware is necessary to attach the bands and splints that keep the jaw stabilized post-surgery.

It's a safe bet that the pre-surgery orthodontia will take at least 6 months, and is not covered by insurance anyway (unless you have exceptionally good coverage). Ideally, by the time she is ready for surgery any waiting period on your plan will have expired.

And finally, getting the surgery approved by the insurance company will probably take months. Be prepared to be denied at first (we had to resubmit at least once).

Please memail me if you have any other questions. Being pain-free and the aesthetic benefits are so, so worth this process.

Good luck!
posted by eiramazile at 3:52 PM on March 31