Pre-existing conditions (Uninsurable) clauses – exclusions 

Pre-existing conditions (Uninsurable) clauses

The Pre X clause no longer applies to Individual or Group Health Insurance as it’s prohibited under Health Care Reform 45 CFR §147.108 and all coverage is GUARANTEED ISSUE §2701

Pre-existing condition exclusion means

a limitation or exclusion of benefits

In the past a Pre X clause (including a denial of coverage) was based on the fact that the condition – Medical Problem was present before covered began whether under a employer group health plan or individual health insurance coverage  and often whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that day.  One needs to review the actual EOC Evidence of Coverage to know for sure.  

A preexisting condition exclusion includes any limitation or exclusion of benefits (including a denial of coverage) applicable to an individual as a result of information relating to an individual’s health status before the individual’s effective date of coverage … such as a condition identified as a result of a pre-enrollment questionnaire – application or physical examination given to the individual, or review of medical records relating to the pre-enrollment period.  ^{54.9801-2   Health Care Reform Facts Q 335}

Here’s some 2024 figures on Medi Cal and other spending on various illnesses.  

Obamacare PROHIBITS discrimination or

different rates based on health!

FAIR HEALTH INSURANCE PREMIUMS. 

§2701 Page 37  HR 3590

‘‘(a) PROHIBITING DISCRIMINATORY PREMIUM RATES.—

‘‘(1) IN GENERAL.—With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual or small group market—

  (A) such rate shall vary with respect to the particular plan or coverage involved only by—

  (i) whether such plan or coverage covers an individual or family;

  (ii) rating area, [county – zip code] as established in accordance with paragraph (2);

Small Biz Rating Methods AB 1083

  (iii) age, except that such rate shall not vary by more than 3 to 1 for adults (consistent with section 2707(c)); and

  (iv) tobacco use, [Doesn’t apply in CA] except that such rate shall not vary by more than 1.5 to 1; and

  (B) such rate shall not vary with respect to the particular plan or coverage involved by any other factor not described in subparagraph (A).

 So does CA Law

§10965.3 (g) (1)

A health insurer shall not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of an individual health benefit plan based on any of the following factors:

(A) Health status.

(B) Medical condition, including physical and mental illnesses.

(C) Claims experience.

(D) Receipt of health care.

(E) Medical history.

(F) Genetic information.

(G) Evidence of insurability, including conditions arising out of acts of domestic violence.

(H) Disability.  

(I) Any other health status-related factor as determined by any federal regulations, rules, or guidance issued pursuant to Section 2705 of the federal Public Health Service Act.

• Think Your Health Care Costs Are Covered? Beware The ‘Junk’ Not ACA Compliant  Insurance Plan
• The relevance of medical history for insurance
• 80% Medical Loss Ratio (MLR) – Actuarial Value
  • CA Insurance Rate Regulation
    • Premium increases? Why are they always going up?
      • Financial Impact of Health Care Reform on Premiums

Underwriting Declinable Conditions Health Questions 

Examples of Declinable Conditions  Medical Underwriting Kff.org  In the Medically Underwritten Individual Market, Before the Affordable Care Act – Group Market before AB 1672 1992 CA :

Condition Condition
AIDS/HIV Lupus
Alcohol abuse/ Drug abuse with recent treatment Mental disorders (severe, e.g. bipolar, eating disorder)
Alzheimer’s/dementia Multiple sclerosis
Arthritis (rheumatoid), fibromyalgia, other inflammatory joint disease Muscular dystrophy
Cancer within some period of time (e.g. 10 years, often other than basal skin cancer) Obesity, severe
Cerebral palsy Organ transplant
Congestive heart failure Paraplegia
Coronary artery/heart disease, bypass surgery Paralysis
Crohn’s disease/ ulcerative colitis Parkinson’s disease
Chronic obstructive pulmonary disease (COPD)/emphysema Pending surgery or hospitalization
Diabetes mellitus Pneumocystic pneumonia
Epilepsy Pregnancy or expectant parent
Hemophilia Sleep apnea
Hepatitis (Hep C) Stroke
Kidney disease, renal failure Transsexualism

Declinable Medications

Anti-Arthritic Medications
Adalimumab/Humira
Cyclosporine/Sandimmune
Methotrexate/Trexall
Ustekinumab/Stelara
others
Anti-Diabetic Medications
Avandia/Rosiglitazone
Glucagon
Humalog/Insulin products
Metformin HCL
others
Medications for HIV/AIDS or Hepatitis
Abacavir/Ziagen
Efavirenz/Atripla
Interferon
Lamivudine/Epivir
Ribavirin
Zidovudine/Retrovir
others
Anti-Cancer Medications
Anastrozole/Arimidex
Nolvadex/Tamoxifen
Femara
others
Anti-Psychotics, Autism, Other Central Nervous System Medications
Abilify/Ariprazole
Aricept/Donepezil
Clozapine/Clozaril
Haldol/Haldoperidol
Lithium
Requip/Ropinerole
Risperdal/Risperidone
Zyprexa
others
Anti-Coagulant/Anti-Thrombotic Medications
Clopidogrel/Plavix
Coumadin/Warfarin
Heparin
others
Miscellaneous Medications
Anginine (angina)
Clomid (fertility)
Epoetin/Epogen (anemia)
Genotropin (growth hormone)
Remicade (arthritis, ulcerative colitis)
Xyrem (narcolepsy)
others

When might there be a Pre-X clause in #Medi-Gap for California Policies 

Maybe if there is Medical Underwriting.  ACA/Health Care Reform didn’t change the rules for Medi Gap.  No pre-x if you enroll during a guaranteed issue time.

Guaranteed issue rights (also called “Medigap protections”)— Rights you have in certain situations when insurance companies are required by law to sell or offer you a Medigap policy. In these situations, an insurance company can’t deny you a Medigap policy, or place conditions on a Medigap policy, like  exclusions for preexisting conditions, and can’t charge you more for a Medigap policy because of a past or present health problem. ^{Publication 02110 page 49}

Insurance Companies cannot discriminate against
victims of #domestic abuse, regardless of sex. ^{(Woods v Horton * Woods v Sherry pdf )  npr.org}

CA Insurance Code § 10144.2

(a) No disability insurer covering hospital, medical, or surgical expenses shall deny, refuse to insure, refuse to renew, cancel, restrict, or otherwise terminate, exclude, or limit coverage or charge a different rate for the same coverage, on the basis that the applicant or insured person is, has been, or may be a victim of domestic violence.

(b) Nothing in this section shall prevent a disability insurer covering hospital, medical, or surgical expenses from underwriting coverage on the basis of the medical condition of an individual so long as the consideration of the condition

(1) does not take into account whether such an individual’s medical condition was caused by an act of domestic violence,

(2) is the same with respect to an applicant or insured who is not the subject of domestic violence as with an applicant or insured who is the subject of domestic violence, and

(3) does not violate any other act, regulation, or rule of law. The fact that an individual is, has been, or may be the subject of domestic violence shall not be considered a medical condition.

(c) As used in this section, “domestic violence” means domestic violence, as defined in Section 6211 of the Family Code.  Abuse 6203 Definition

See also Health & Safety Code 1374.75

CA Insurance Code 676.9.

(a) This section applies to policies covered by Sections 675 and 675.5.

   (b) No insurer issuing policies subject to this section shall deny or refuse to accept an application, refuse to insure, refuse to renew, cancel, restrict, or otherwise terminate, or charge a different rate for the same coverage, on the basis that the applicant or insured person is, has been, or may be, a victim of domestic violence.

   (c) Nothing in this section shall prevent an insurer subject tothis section from taking any of the actions set forth in subdivision(b) on the basis of criteria not otherwise made invalid by thissection or any other act, regulation, or rule of law. If discrimination by an insurer is not in violation of this section butis based on any other criteria that are allowable by law, the fact that the applicant or insured is, has been, or may be the subject ofdomestic violence shall be irrelevant.

   (d) For purposes of this section, information that indicates thata person is, has been, or may be a victim of domestic violence ispersonal information within the meaning of …Section 791)

   (e) No insurer that issues policies subject to this section, and no person employed by or under contract with an insurer that issues policies subject to this section, shall request any information the insurer or person knows or reasonably should know relates to acts of domestic violence or an applicant’s or insured’s status as a victim of domestic violence, or make use of this information however obtained, except for the limited purpose of complying with legal obligations, verifying a person’s claim to be a subject of domestic violence, or cooperating with a victim of domestic violence in seeking protection from domestic violence or facilitating the treatment of a domestic violence-related medical condition. This subdivision does not prohibit an insurer from asking an applicant or insured about a property and casualty claim, even if the claim is related to domestic violence, or from using information there by obtained in evaluating and carrying out its rights and duties under the policy, to the extent otherwise permitted by this section and other applicable law.

   (f) As used in this section, “domestic violence” means domestic violence as defined in Section 6211 of the Family Code.

FAQ’s 

• Are you repealing patient protections, including for people with pre-existing conditions?
• No. Americans should never be denied coverage or charged more because of a pre-existing condition.
• We preserve vital patient protections, such as (1) prohibiting health insurers from denying coverage to patients based on pre-existing conditions, and (2) lifting lifetime caps on medical care. housegop.leadpages.co/healthcare
• ***
• Thus, the rest of this  page is pretty much Historical
  
• Seniors & Medicare Supplements
   Medicare Advantage Plans
  Part D – Rx – Prescriptions
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• Waiving the Pre X Clause – Once I’m able to get coverage

1. If I have prior medical insurance “Credible Coverage” and I get new health coverage will my  pre-existing conditions be covered?
2. If I do not have prior Credible Coverage will  my pre-x be excluded forever, or just for say 6 months or a year
3. What about the Pre X clause in visitor and travel policies?

• Claims Issues?

1. What if something else makes the Pre-X worse, my pre-x causes a new problem, that is, how does the Insurance Company decide if the medical expense claim was from the Pre-X?
2. What if I have say Hypertension – how would it be determined if that was the nexus or aggravation of say a Heart Attack?
3. If I have a policy in force and then I get sick or develop a Pre – X  can they cancel me or raise my rates?
4. How can I appeal, complain or file a grievance?
5. Does Obama’s Plan prohibit recessions Nationally?
6.  

• Misc.

1. Where can I find Federal Regulations §146.111 or §2590.701-3 on Pre-X limitations?
2. How will Obama’s Plan affect Pre-Existing Conditions?
3. How do I get help if I’m not in California?
4. Are there any Federal, State AB 88 or protections in Obama’s plan for Mental Illness?

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• Underwriting
• In Individual plans Insurance Companies generally have the right to decide to give you a policy on not.  This is called Underwriting.
• CA Department of Insurance Listing of  typical Pre-existing conditions
• If there are any waiting periods in your new coverage, they are generally waived if 63 days of terminating your Insurance with another “creditable” health care plan.
• One Page – Pre Underwriting FORMS
• Do NOT miss your HIPAA 63 day deadline!
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• When must a health plan write me?
• In CA under AB 1672 Small Employer Health Act §10705 j you can not be excluded as an employee or dependent in a group plan for health status.   Employer group of 2 or more are guaranteed coverage.
• Mr. MIP Guaranteed coverage for individuals rejected from standard plans.
• Obama’s Interim High Risk Guaranteed Pool However, this plan just ran out of funding.
• Guaranteed Issue & Plans for Uninsured
• Federal Law 1182 – Group Plans must treat all similarly situated employees the same, regardless of health status.
• Steve, you’re website is the greatest, but I don’t live in California
• Guarantees for those who lost Employer Group Health Insurance
• COBRA and when that expires in 18 months or 36 months in California, then you can get a “HIPAA” policy
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• How long is the Pre-X clause?
• In CA Group Plans, not more than 6 months 10198.7
• This clause can often be waived!
• Government Tools to help find coverage
• Case Law on Pre-Existing Conditions
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• What if a don’t tell the Insurance Company about my medical history?
  • Be sure to disclose whatever is asked for in the application, so that there isn’t a recession – cancellation later.  Just because you paid cash or were treated by someone whose records are not available, doesn’t mean that just because it’s not on your “record” that it doesn’t count.  In some cases, the Insurance Company will have your doctor verify your conditions on your first visit with your new coverage.
  • Do NOT call or contact us in any way,  if you plan to misrepresent yourself on an application for Insurance.  We do not need the grief or the fine.   We are mandated by law to certify that we do not know anything negative that is not on the application and that we explained to you how important it is to fill out an application correctly.  We pride ourselves on helping the public get paid on LEGITIMATE claims and issues.
• Preexisting conditions, proximate cause
• When two causes join in causing injury, one of which is insured against, insured is covered by policy.  ^{Zimmerman v. Continental Life Ins. Co. (App. 1 Dist. 1929) 99 Cal.App. 723, 279 P. 464.  Wiki Answers  Ins.Code § 10320  exclusions must be listed in the policy itself.}
• 10198.6.  Preexisting Condition Provisions and Late Enrollees
  10198.7.  (a)
• top
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• Is one condition the nexus or aggravation of another?  top
• Lastly, the veteran must have a nexus [connection]  between the current disability and the in service disease injury or incident.
• In other words, there must be a link between the present disability and the veterans time during his period of active military service.
• There are many ways in which the veterans present disability can be connected to his disease, injury or incident in service. The VA is required to consider all the possible ways to disability could be service-connected.
• Probably the most common is direct service connection. This is when a disease, injury or incident in service directly caused the veteran’s present disability. These cases are usually won when you have a letter from a doctor stating that the in service disease, injury or incident was the cause of the veteran’s present disability. Because the veteran is given the benefit of the doubt a doctor only needs to be 50% sure that the in service condition caused the present disability. The language the VA accepts is that it is “at least as likely as not” that the veterans present disability is a result of the specified disease injury or incident in service. If the doctor uses the terminology that it is less likely than not he or she is saying they are less than 50% sure there is a connection. And if the doctor uses the terminology that “it is more likely than not” then he or she is saying there is a greater than 50% chance that the in service disease injury or incident caused the veterans present disability. These opinions from doctors are often called Nexus letters. If you are seeking a nexus opinion from your doctor it is extremely important the doctor is aware of the terminology used by the VA. It is also important for these opinion letters that the doctor have access to, review and state that he has reviewed your file and service medical records. If the doctor references the file in service medical records it strengthens the opinion even more. These opinion letters are even more important when you’re trying to prove service connection for a present condition many years after service.
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• A veteran will have to show aggravation of a condition in service if the condition preexisted his service time. If the veteran can show his condition has worsened as a result of his time in service than the VA has the burden to prove that the worsening of the condition was due to “the natural progression of the disease.” One presumption in VA law that helps in these types of cases is the “presumption of soundness.” This means the veteran is presumed to be in sound condition when he entered service in less shown otherwise usually by the service entrance exam icdri.org/
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• rbs law.com/
• veterans disability lawyer site.com
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• Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections
• Regulation
• Fact Sheet
• Patient Protection Model Notice
• Lifetime Limits Model Notice
• Public Comments
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• With Guaranteed Issue Coverage coming 1.1.2014 many employees may leave their jobs to start new businesses.  www.SteveShorr.com has been helping Small Biz with 2 or more employees in CA get guaranteed coverage since 1992 under AB 1672, Mr. Mip for individuals if they had no place else to go and HIPAA for those who have exhausted COBRA.    We welcome NEW start ups.  Free Individual  Business  Quotes
• It’s our opinion that under Health Care Reform that ONE employee business, even if it’s just the owner can get GROUP coverage.  There is  some dissenting opinion.  We’ve sent a email to Covered CA for clarification.
•  
• References
• ‘Employment Lock’ May Be Coming to an End
• Meanwhile, a new paper explores the phenomenon of “employment lock” — where workers stay in jobs they don’t like because of the health benefits — and concludes that given the new security of coverage expansion under the ACA, as many as 940,000 Americans will leave their jobs.
  (CA Healthline)
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• • No. The ObamaCare prohibition against Pre-Exisitng Conditions includes any limitation or exclusion.