Should I hold off on seeking treatment under my new health insurance coverage?

April 28, 2012 10:22 AM

Specific pre-existing condition health insurance question.

After not having any insurance for several years, I just started a new job with a large US employer and have a group PPO plan. My coverage was effective from day one of employment. I have two non-critical health issues for which I need to see an MD, one of which I have sought treatment for in the past, one of which I have not. I would also like to begin seeing a mental health provider for help with an issue I've not had diagnosed, though I have seen a psychiatrist in the past.

All of these issues have been present for longer than my current coverage.

Is it a bad idea to begin seeking treatment for all of these issues right away? If so, what is a reasonable waiting period?

My initial response would be "yes, it's a bad idea", but I've seen some mention of the fact that pre-existing conditions are not usually an issue with group-based plans from large employers. However, I definitely have not had continuous coverage, which I understand makes a difference.

I am also hesitant to call up my insurer or my employer and give them advance notice that I have these issues by asking specific questions about coverage and policies.

posted by anonymous to Health & Fitness (8 answers total)

but I've seen some mention of the fact that pre-existing conditions are not usually an issue with group-based plans from large employers.

These people are correct. Pre-existing conditions are only a problem when trying to obtain insurance on your own.
posted by futz at 10:27 AM on April 28, 2012

You should ask your employer for a copy of the summary plan description for your health plan. It's a perfectly normal thing to ask for, and in fact you should really have a copy for your reference anyway, so you won't be tipping your hand to your employer.

There should be fairly plain language in there around exactly what pre-existing condition exclusions exist, if any - for instance, mine says "This Plan imposes no preexisting condition exclusion. This means that if you have a medical condition before becoming a member of the plan, you will not have to wait a certain period of time before the Plan will provide coverage for that condition."

But yes, if you have group insurance through a large employer, it's all but certain there are no pre-existing condition exclusions.
posted by strangely stunted trees at 10:31 AM on April 28, 2012

But yes, if you have group insurance through a large employer, it's all but certain there are no pre-existing condition exclusions.

Probably, but really make sure of this. I feel like most employers/people assume everyone is coming from another group plan with no gap in coverage. Coming from an individual plan or having a gap in coverage sometimes changes things.

While you're at it, double check that you don't need a referral from a general doctor if you're planning on going straight to specialists (mental health care or otherwise). Since it's a PPO I doubt you do but it never hurts to double check when dealing with the healthcare industry.
posted by Bunglegirl at 11:34 AM on April 28, 2012

seconding strangely stunted trees.
Highly doubtful that there would be any preexisting exclusions, but double check the policy to make sure.
posted by SLC Mom at 1:07 PM on April 28, 2012

Huh, most of the group policies I've seen in the last year have a pre-existing conditions exclusion period. It is usually six months. This means after six months of coverage they will cover your pre-existing conditions.

This time period can be shortened by having creditable coverage right before your new plan, basically each month of creditable coverage in the previous 6 months cuts one month off your exclusion period. Six months of coverage means no exclusion period.

So yeah, DEFINITELY check your plan documents or ask you HR person, they should know off the top of their head.
posted by magnetsphere at 1:33 PM on April 28, 2012

Ask your HR person, but also ask them to show your the relevant documentation. I'm sure that there are some awesome HR people out there, but I haven't worked with many.
posted by kaybdc at 1:40 PM on April 28, 2012

Pre-existing conditions are a negotiable issue, just like anything else. Really large companies have the leverage to tell the insurance company that pre-existings won't be considered. My 20 employee employer has an awesome health plan that didn't factor in pre-existings. But that is because it's important to management, and we pay dearly for that kind of policy.

If the enrollment form didn't ask - odds are you are fine, but it's not 100%. Just ask HR - especially if it is a big company they probably get that question several times a day.
posted by COD at 3:57 PM on April 28, 2012

Please don't take anyone's prediction that there won't be any preexisting condition exclusion provisions for granted - do take the advice to read your plan's SPD.

My large international corporation's plan applies preexes (and, in fact failed to send some required information - the general notice of preex when I was hired), it just didn't happen to matter to me, as I've been continuously covered.
posted by Pax at 11:52 AM on April 30, 2012