How to get details of coverage for a preexisting condition?
March 18, 2015 12:39 PM Subscribe
USA insurance-filter: we can't have kids naturally and need either surgery or IVF. We are on my wife’s insurance, which does not cover either of these. My employer's insurance says it does, but before we switch I want to be very sure these things are covered and understand any limitations. Can I just ask the insurer directly?
Our fertility MD tells us that it is very, VERY unlikely that we can conceive naturally and our options are surgery to correct the issue or go directly to IVF. We are weighing these options, and since both are expensive cost and insurance coverage is a factor.
We are currently on my wife’s employers insurance, which very clearly does not pay for any fertility-related treatments. I took a look at my employers insurance, and the short summary I got says they cover fertility treatments. So we are considering switching during my employer’s next open enrollment period which is just a few months away. It’s my understanding that before Obamacare we would have been in trouble because they would refuse to cover this pre-existing condition, but now that pre-existing conditions have to be covered so if we switch to my employers insurance we should be eligible to be covered for fertility treatments. I would like to speak to my employer’s insurer directly and get written confirmation of what fertility treatments are covered and any relevant requirements (do we have to try one thing before the other? Which procedures are covered?). However, I have in the back of my mind the idea that you should never admit a pre-existing condition to a possible insurer because they might deny you coverage or charge you differently. Is it still the case that admitting a pre-existing condition to a potential insurer is a bad idea? Or can I safely speak to them now since being denied coverage for a pre-existing condition is a thing of the past?
Our fertility MD tells us that it is very, VERY unlikely that we can conceive naturally and our options are surgery to correct the issue or go directly to IVF. We are weighing these options, and since both are expensive cost and insurance coverage is a factor.
We are currently on my wife’s employers insurance, which very clearly does not pay for any fertility-related treatments. I took a look at my employers insurance, and the short summary I got says they cover fertility treatments. So we are considering switching during my employer’s next open enrollment period which is just a few months away. It’s my understanding that before Obamacare we would have been in trouble because they would refuse to cover this pre-existing condition, but now that pre-existing conditions have to be covered so if we switch to my employers insurance we should be eligible to be covered for fertility treatments. I would like to speak to my employer’s insurer directly and get written confirmation of what fertility treatments are covered and any relevant requirements (do we have to try one thing before the other? Which procedures are covered?). However, I have in the back of my mind the idea that you should never admit a pre-existing condition to a possible insurer because they might deny you coverage or charge you differently. Is it still the case that admitting a pre-existing condition to a potential insurer is a bad idea? Or can I safely speak to them now since being denied coverage for a pre-existing condition is a thing of the past?
As of 2014, you can’t be denied coverage, charged more, or denied treatment based on health status or preexisting conditions.
If the insurance is through your employer, then your employer has pre-negotiated the rate each employee will pay. The insurance company can't change that rate on individual employees, because the plan is a group plan.
posted by erst at 12:51 PM on March 18, 2015 [3 favorites]
If the insurance is through your employer, then your employer has pre-negotiated the rate each employee will pay. The insurance company can't change that rate on individual employees, because the plan is a group plan.
posted by erst at 12:51 PM on March 18, 2015 [3 favorites]
Call your HR. They may have an ombudsman or a designated contact for insurance issues who can help you interpret the policy before you sign on the dotted line.
Since pre-existing conditions are no longer a concern due to the ACA, there will be no penalty if you disclose to your insurer. I don't think you need to be concerned at all. On the contrary, I think you should be as detailed as possible when you ask, and make sure to get everything in writing.
posted by blnkfrnk at 1:15 PM on March 18, 2015 [2 favorites]
Since pre-existing conditions are no longer a concern due to the ACA, there will be no penalty if you disclose to your insurer. I don't think you need to be concerned at all. On the contrary, I think you should be as detailed as possible when you ask, and make sure to get everything in writing.
posted by blnkfrnk at 1:15 PM on March 18, 2015 [2 favorites]
Pre existing conditions aren't really a concern any longer, but make sure the plan is ACA complaint when you give them a call. Some plans are grandfathered in and aren't up to snuff yet.
posted by Attackpanda at 1:31 PM on March 18, 2015 [1 favorite]
posted by Attackpanda at 1:31 PM on March 18, 2015 [1 favorite]
Weighing with everyone else, you can no longer be denied treatment for preexisting conditions. FWIW, I've had psoriatic arthritis since my 20s and have had several jobs since then. I have never had trouble with getting treatment covered for this condition through any health insurance provided by my employer, although pre-ACA it would have been an issue for me if I had needed to get health insurance as a private individual. As someone already mentioned, your employer has already negotiated the rates for any plans that they're offering. It may affect plan prices the following year/negotiating period if a certain number of employees (either new hires or current employees) have or develop conditions that are expensive to treat/require lots of visits, but even if that happened the increases would be across the board, not targeted at individual employees. I may have that wrong, but it's my understanding that that was one of the factors against hiring older candidates (that they would drive up insurance costs).
All that being said, they still can make you (and your doctor) jump through a lot of hoops prior to approving more expensive treatments and there may be some things (certain drugs for example) that they never cover. I believe some plans also have different tiers of % of coverage for various types of drugs/treatments (eg. Generic drugs might be covered at 100%, but they might only cover 70% of the cost for a brand name drug). So definitely try to find out exactly what types of fertility treatments they cover.
I think that while the HR rep can provide you with the informational packets for any plans you offer, only a rep from the insurance company will be able to answer more detailed questions regarding coverage of specific treatments.
posted by kaybdc at 8:40 PM on March 18, 2015 [1 favorite]
All that being said, they still can make you (and your doctor) jump through a lot of hoops prior to approving more expensive treatments and there may be some things (certain drugs for example) that they never cover. I believe some plans also have different tiers of % of coverage for various types of drugs/treatments (eg. Generic drugs might be covered at 100%, but they might only cover 70% of the cost for a brand name drug). So definitely try to find out exactly what types of fertility treatments they cover.
I think that while the HR rep can provide you with the informational packets for any plans you offer, only a rep from the insurance company will be able to answer more detailed questions regarding coverage of specific treatments.
posted by kaybdc at 8:40 PM on March 18, 2015 [1 favorite]
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Ask your employer to see an EoB for the plan, the details may be outlined on that already and a call to the insuruer would just be a confirmation.
Depending on the size of your employer you might have a benefits admin and/or use a third party insurance broker. They would also be good people to ask.
posted by phunniemee at 12:48 PM on March 18, 2015 [2 favorites]