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Can my group plan exclude my wife's $2,000-a-month drug?

Consumer Reports News: January 11, 2013 09:38 AM

Q. My wife just got laid off from her job, which has been supplying our health insurance for the past 15 years. I'm switching to my employer's plan but it says that pre-existing conditions won't be covered for the first 12 months. My wife needs a $2,000 monthly infusion of a drug to control an autoimmune condition, and we can't afford it on our own. What recourse do we have?

A. Relax, your wife's condition will be covered from day one when you switch, thanks to a 1996 federal law, the Health Insurance Portability and Accountability Act (HIPAA), that was designed in part to solve exactly this sort of problem. HIPAA says that if you switch from one employer plan to another, with less than a 63-day break, the new plan's exclusion period for pre-existing conditions is shortened by as long as you were on the old plan. In other words, if you were switching after six months under a prior plan, the exclusionary period would be shortened from 12 months to six months. But in your case, you've been on your wife's plan for a lot more than 12 months, so the entire exclusionary period is eliminated.

When your wife's former coverage ends, her health plan will send her a document called a "certificate of creditable coverage." Hang on to it, because if your new plan gives you any grief about covering your wife's expensive drug, it's proof that she had qualifying coverage that eliminates that exclusionary period. If you don't get it, ask for a copy; you have a right to it, needless to say.

This isn't the first time I've gotten this question. It's too bad this law isn't better known because it's hugely helpful in situations like yours.

For more information, see our Health Insurance Buying Guide as well as rankings of health insurance plans. Got a question for me? Ask it here.

Source:
Your Health Plan And HIPAA...Making The Law Work For You [U.S. Department of Labor]

Nancy Metcalf

   

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