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Insurance Coverage: Pre-existing Conditions, Rankings, the Right Plan



A pre-existing condition is any illness, condition or treatment performed or diagnosed within the last 12 months before starting a new health insurance plan.  It can be a broken foot, allergies, heart disease or anything else.  Up to now, insurance companies could cover your medical expenses in a new policy, but exclude coverage of the pre-existing conditions.  Ironically, that is exactly why one needs health insurance!  The good news is that Healthcare Reform changed that in March 2010!

Pre-Existing Conditions - Understanding Exclusions and Creditable Coverage
HIPAA Pre-Existing Condition Protections
From Michael Bihari, MD, former Guide
Updated April 15, 2010 Health's Disease and Condition content is reviewed by our Medical Review Board

“Effective September 2010, children (below age 19) with pre-existing conditions may not be denied access to their parents' health plan and insurance companies will no longer be allowed to insure a child, but exclude treatments for that child's pre-existing condition.  Starting in 2014, this provision will apply to adults as well.”

Each insurance company has its own rules regarding pre-existing conditions and how they affect new coverage.  It is best to ask if a particular condition or treatment will be covered by the new policy. 

Furthermore, HIPPA provides additional protection when making changes or continuing health insurance.



“An important feature of HIPAA is known as “creditable coverage.”

Creditable coverage is health insurance coverage you had before you enrolled in your new health plan, as long as it was not interrupted by a period of 63 or more days. The amount of time you had “creditable” health insurance coverage can be used to offset a pre-existing condition exclusion period in your new health plan.

The bottom line: If you had at least a full year of health coverage at your previous job and you enrolled in your new health plan without a break of 63 days or more, your new health plan cannot subject you to the pre-existing condition exclusion.”

The following link provides some information on how HIPPA can help with common occurrences, including naming illnesses or conditions that cannot be excluded from coverage as a pre-existing condition: pregnancy, genetic information [such as a gene showing higher risk of breast cancer], or conditions present in a newborn or adopted child under the age of 18.

FAQs About Portability Of Health Coverage And HIPAA



Pre-existing Condition Insurance Plan, or P.C.I.P.

If you do have pre-existing conditions and insurance carriers insist on excluding them in a new policy - usually for the first 6-12 months or so - you may want to consider a Pre-existing Condition Insurance Plan, or P.C.I.P.  Once you have the premium of a new policy, adding doctors’ visits, medications, treatments and any other out-of-pocket expenses that your health will require during the initial 6 - 12 months, you can compare those costs with a P.C.I.P.  If you don’t anticipate a lot of expenses during the exclusion period, it could be that the excluding policy may work out best for you after all.

The New York Times article below gives us a basic look at P.C.I.P.’s: Finding a Plan, Eligibility Restrictions and The Right Coverage.  P.C.I.P.’s can be a suitable alternative to going without coverage or to more expensive options offered by private insurance companies.

Patient Money
Pre-existing Condition? Now, a Health Policy May Not Be Impossible
Published: March 18, 2011

FINDING A PLAN Pre-existing condition insurance plans, required by the new health care law, opened for business in July. The new plans come in two flavors: 27 states run their own plans with federal money, while the rest rely on the federal Department of Health and Human Services to administer the plans within their borders...

To find a plan in your state, start with the federal government’s Web site,, which offers lots of application information and details about each of the state plans the department administers. An interactive map at links to each federal- and state-run plan.

Next, you will need to compare the plan offerings in your state. Federally run P.C.I.P.’s offer three options: standard coverage; extended coverage, with a lower deductible and higher premiums; and an option that combines a high deductible with a health savings account. For a side-by-side comparison of the three choices, click on Premiums for all three options are also listed online.

State plans that are not administered by the federal government may also offer more than one option. The details can be found at the interactive state map mentioned above.

People without access to the Internet can call the Department of Health and Human Services at 866-717-5826 to find out which plans are available in their states.

ELIGIBILITY RESTRICTIONS The plans were not intended to solve the health insurance mess. They were intended as a temporary Band-aid, and they have some frustrating limitations.

...You must be uninsured for at least six months to be eligible for a plan. That means people already enrolled in state high-risk pools or private insurance cannot apply, even if the new plans would be far less expensive. Unemployed people who are on Cobra or whose benefits have only recently expired are also not eligible.





We're GEHA, and we are administering the Pre-Existing Condition Insurance Plan (PCIP) in more than 20 states for the U.S. Department of Health and Human Services (HHS). Enrollees can now choose from three distinct plan options. Click to see plan option benefits.

PCIP was created as part of the Affordable Care Act. The PCIP program provides a new health coverage option for you if you have been uninsured for at least six months, you have a pre-existing condition or have been denied health coverage because of your health condition, and are a U.S. citizen or are residing here legally. For more about PCIP, click on Frequently Asked Questions.

Plan Materials

2011 PCIP Benefits Summary  (2011 Spanish-language Benefits Summary)
This piece provides an overview of PCIP benefits for 2011.

2011 PCIP Brochure
This brochure describes the benefits, exclusions, limitations and maximums of the Pre-Existing Condition Insurance Plan for 2011.

Medco By Mail Order Form
PCIP enrollees use this form when mailing new prescriptions to the Medco By Mail pharmacy.

Medco Health, Allergy & Medication Questionnaire (HMQ)
Medco requests that PCIP enrollees complete this form once a year to protect against potentially harmful drug interactions and drug allergies.

Direct Reimbursement Claim Form
PCIP enrollees should use this form to submit prescription receipts when a participating pharmacy is not available.

Premium rates
Click on your state below to see the monthly premium rates for each of the three PCIP plan options.
Alabama  |  Arizona  |  D.C.  |  Delaware  |  Florida  |  Georgia  |  Hawaii  |  Idaho  |  Indiana  |  Kentucky  |  Louisiana  |  Massachusetts  |  Minnesota  |  Mississippi  |  North Dakota  |  Nebraska  |  Nevada  |  South Carolina  |  Tennessee  |  Texas  |  Vermont  |  Virginia  |  West Virginia  |  Wyoming

If your state is not listed above, then it has opted to run the PCIP program itself. For more information on states not listed above, go to

How to apply
To apply for the PCIP plan, click on Apply Now.




Review your coverage options carefully. In the plans sponsored by the federal government, all three options cover 100 percent of preventive care, like annual physicals and screenings. All charge a 20 percent co-pay (40 percent for out-of-network providers) for other care, with a $5,950 out-of-pocket annual maximum for in-network care ($7,000 for out of network).
The difference is in the deductible. The standard plan has a $2,000 deductible for in-network care ($3,000 for out of network), compared to the extended plan’s $1,000 and $1,500 deductibles.
...If you can afford the higher out-of-pocket costs, it may make sense to opt for lower premiums.


Exploring insurance carriers for our own personal insurance coverage, I have come to the conclusion that if you use a lot of prescription drugs, you need to make sure that your plan covers your drugs.  I found out that some plans do not cover a drug at all - meaning you have to pay for it yourself, or they have limits on the quantities they will cover.  If the latter is the case, you can submit a form to the insurance carrier requesting that they cover your drugs along with your doctor's justification for the drug.  No guarantee of coverage, but there is a chance.  This could result in increased medical costs beyond your premium and copays.

Let me emphasize the importance of requesting the right coverage for the required services from the beginning.  I passed on some types of coverage because I didn't think we would need them.  Well, it looks like I may, but I was told by Golden Rule that I cannot add the benefit to my policy.  If I cancel it and buy a new one, they will only offer me the exact same coverage I just got and terminated.  If I terminate my policy now, they would allow me to get a new policy with the additional benefit AFTER 6 months.  This means that I would have to have a different insurance carrier for the next 6 months or have no insurance for that time period.  That would, of course, leave me uninsured for longer than 63 days and affect my continuous coverage that insurance carriers want you to have.  Obviously, if I found another carrier that would have the additonal benefits I seek, I'd just stay with them long term.

It seems to me that in a year, you spend about the same for different policies - difference of about $1000-2000 / year or $83-166 / month.  The difference is how you spend your money: high monthly premium - lower deductible / total out-of-pocket expense; low monthly premium - higher deductible / total out-of-pocket expense.  You end up spending more in a year with the lower monthly premium with the plans I compared for Medicare Part D [Drug plan], which were 2 Blue Cross Blue Shield plans [Value & Plus], United Health Care, and Medco Health [Value & Choice].  Because I don't know for sure if 3-4 drugs will be covered, I cannot get an accurate cost for any plan.





Finding insurance coverage can definitely sound intimidating and complicated to those of us who have never taken on this task before.  Insurance carriers have a language of their own and it behooves you to become knowledgeable about the basic terminology or you could end up buying insufficient, inadequate or unnecessary coverage.  Finding out that a particular treatment is not covered can only add stress to an already delicate situation.
  is a great website that presents to you live quotes from various carriers after answering a few questions about your needs and location.  The types of insurance that they offer are small business, family and individual, short-term, dental, travel and life.  You can also speak with a licensed agent, who will answer your questions or guide you through an application.

Another option is to call the specific insurance carrier and speak with a representative.  S/he can answer all sorts of questions [see my list below] and suggest appropriate coverage based on your needs and budget.  You may then fill out an application online on your own or allow a rep to guide you through the process.  All of the reps with whom I spoke were very helpful and patient.

I suggest that when shopping for insurance coverage, unless you are well-versed on the subject, you listen and ask questions about anything that is not crystal clear to you.  You, after all, are the customer who will be giving them your money in exchange for their services.  You want to be sure you understand what exactly you are buying!

Below is a list of suggestions on how to find the right insurance coverage for when you are shopping around for insurance carriers:

  1. Before you call anyone, have a notebook and pen ready.
  2. Write down any illnesses, conditions, medicines or treatments that you or your family requires.
  3. Write down how much money is spent on medicines each month - both total retail amount & what you pay out-of-pocket.  [You want to be sure that your policy will cover medications adequately, since this is usually a separate agreement between the insurance carrier and a prescription drug plan carrier.]
  4. Write down your current monthly premium, yearly deductible and total out-of-pocket expenses - individual and family, as well as how much you can afford in case the monthly premium needs to be higher.
  5. Write down your current copay for doctor’s visits as well as for medicines.
  6. Write down any limits - for example, dental coverage can have a yearly limit.
  7. Go online to search carriers or call if you prefer to speak to an agent.  A list of websites follows below.
  8. Tell the agent what you truly need and let him / her tell you what s/he can offer you.
  9. Take notes.  Ask questions about anything that isn’t clear to you.
  10. Learn the terminology!  Do you know what coinsurance is?  Ask if you’re not sure!
  11. Ask when coverage would begin - if you need coverage sooner, ask if they can expedite the process or whether they sell short-term policies to cover you until their long-term policy begins.
  12. Ask about pre-existing conditions - are they covered right away?
  13. Ask if they have a waiting period for any treatments or services - some dental plans make you wait 14 days or longer to cover certain procedures.
  14. Confirm that preventive visits, such as physicals & mammograms are 100% covered right away - it’s the law!

8 Keys to Picking the Best Individual Health Insurance Policy
Shopping for healthcare coverage on your own? Here's what to consider
By Megan Johnson
Posted: January 24, 2011


Understanding Health Insurance  -  from Consumer Reports

Discusses the basics of how health insurance works - know what your coverage is; what you should look for in a health-insurance plan.




If you’re not sure what the difference between COINSURANCE and COPAYMENT is, better take a look at the websites below. Glossary

Complete Glossary of Health Insurance Terminology

Common terms:

From Complete Glossary of Health Insurance Terminology 

annual maximum benefit amount. The maximum dollar amount set by an MCO that limits the total amount the plan must pay for all healthcare services provided to a subscriber in a year.

broker. A salesperson who has obtained a state license to sell and service contracts of multiple health plans or insurers, and who is ordinarily considered to be an agent of the buyer, not the health plan or insurer.

coinsurance. A method of cost-sharing in a health insurance policy that requires a group member to pay a stated percentage of all remaining eligible medical expenses after the deductible amount has been paid.

copayment. A specified dollar amount that a member must pay out-of-pocket for a specified service at the time the service is rendered.

deductible. A flat amount a group member must pay before the insurer will make any benefit payments.

fee schedule.18 The fee determined by an MCO to be acceptable for a procedure or service, which the physician agrees to accept as payment in full. Also known as a fee allowance, fee maximum, or capped fee.

Medicaid. A jointly funded federal and state program that provides hospital expense and medical expense coverage to the low-income population and certain aged and disabled individuals.

Medicare. A federal government hospital expense and medical expense insurance plan primarily for elderly and disabled persons. See also Medicare Part A, Medicare Part B, and Medicare Part C.

Medicare Part A. The part of Medicare that provides basic hospital insurance coverage automatically for most eligible persons. See also Medicare.

Medicare Part B. A voluntary program that is part of Medicare and provides benefits to cover the costs of physicians' services. See also Medicare.

Medicare Part C. The part of Medicare that expands the list of different types of entities allowed to offer health plans to Medicare beneficiaries. Also known as Medicare+Choice. See also Medicare.

Medicare supplement. A private medical expense insurance plan that supplements Medicare coverage. Also known as a Medigap policy.

network. The group of physicians, hospitals, and other medical care providers that a specific managed care plan has contracted with to deliver medical services to its members.

out-of-pocket maximums. Dollar amounts set by MCOs that limit the amount a member has to pay out of his or her own pocket for particular healthcare services during a particular time period.

pre-existing condition. In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage.  [I have seen 6 months with some insurance carriers.]




It sounds like a nuisance, but it is well worth the effort to make notes about your health requirements and to know what you can afford so that you don’t forget to mention something important when the agent is giving you lots of information with which you may not be familiar.

Once you have the information for one carrier, you can get the same details for another one or two, then compare all of them. 

Two things that will make a big difference in your monthly premium are the yearly deductible and total out-of-pocket amounts.  The lower the deductible, the higher the monthly premium.  You’ll need to consider your monthly and yearly medical expenses, as well as your general health.  Do you require costly medications regularly?  Are you a low-maintenance, healthy person?  Are all persons on the policy fairly similar in general health, or does one need a lot of care?  In such a case, you may want to consider getting two different policies so that the healthier members of the family do not end up paying a higher premium for coverage that they may never need.  That turned out to be the case in our family.  We got a policy with a high deductible [$10,000] & low monthly premium for 3 healthy people [$275] and a separate policy with a lower deductible [$3500] and higher monthly premium [$462] for the family member with serious health issues.  We ended up saving $596 per month!  Actually, we saved even more because the family policy now includes our 23-year old son, who had been dropped from our previous policy when he turned 21.  An insurance agent actually suggested this, so tell them your situation as it is.

I spoke with insurance brokers as well as representatives of particular insurance carriers.  Both provided useful information that allowed me to ask the next company about specific coverage - something I would not have thought of myself.  So ask questions,  listen & take notes!

Provides information on different plans & carriers; compares plans and deductibles.  Live agents available.

Provides information and answers to health care questions, as well as providing quotes for coverage.  Information also available on other types of insurance, such as homeowners, business and travel.






The Top 25 Health Insurance Companies - ranked by market share in 2009, the latest available:

#1    Unitedhealth Group
#2    Wellpoint Inc. Group
#3    Kaiser Foundation Group
#4    Aetna Group
#5    Humana Group
#6    HCSC Group
#7    Coventry Corp. Group
#8    Highmark Group
#9    Independence Blue Cross Group
#10    Blue Shield of CA Group
#11    Cigna Health Group
#12    BCBS of MI Group
#13    Health Net of California, Inc.
#14    BCBS of NJ Group
#15    BCBS of FL Group
#16    Regence Group
#17    BCBS of MA Group
#18    Carefirst Inc. Group
#19    Wellcare Group
#20    HIP Ins. Group
#21    Metropolitan Group
#22    Unumprovident Corp. Group
#23    Universal Amer Fin Corp. Group
#24    Lifetime Healthcare Group
#25    BCBS of NC Group


NCQA Accreditation ratings summarize overall plan performance on a number of standards and measures. Plans with a higher NCQA Accreditation status can be generally expected to provide better care and service than plans with lower accreditation statuses.

This website rates health insurance plans by state and the District of Columbia.  It includes a Recognized Physician Directory specializing in different medical fields like diabetes, back pain or stroke, as well as tips on how to choose a good health plan that serves your needs.

Member Health Plan Ratings by state.  This website contains ratings for Autos, Finance, Home Builders, Electronics and several other categories as well.

This website contains rankings of health plans including Medicare and Medicaid HMOs, PPOs, Private HMOs as well as tips on choosing a good health plan.

It also provides information on Prescription Drugs, Doctors & Hospitals by state, Conditions & Treatments, and products for Healthy Living.


TYPES OF INSURANCE provides information about different types of insurance policies to suit different lifestyles and healthcare needs.



Find carriers with plans that may suit your needs when you are between jobs.





From UnitedHealthOne, underwritten by Golden Rule Insurance Company,

Some tips to take good care of yourself and save money on healthcare follow:

  • Take control of your health.  Sleep and exercise more.  Eat better.  Stop smoking.
  • Don’t ignore symptoms.  Catch problems before they’re serious.
  • Wash your hands to help stop the spread of viruses.
  • Manage your weight.  Many healthful vegetables cost less than processed foods.  Smaller portion sizes can help you lose weight and cut grocery costs.
  • Before you visit a doctor, call to verify she or he is still in the provider network.
  • Let your doctor know you want to save money.  Ask for generic prescriptions when needed.  Ask for prescription samples.  Check drug company websites for coupons or special offers.
  • Don’t use the emergency room as a substitute for an office visit.
  • Read your medical bills closely.  If you find an error, send us a letter detailing the error.
  • Health Savings Account customers can save more by maximizing the tax advantages of their HSAs.  If you have an HSA, deposit the most you can afford each year up to the legal limit.  Remember, funds can be used tax free for many out-of-pocket medical expenses, like dental and vision care.


We all have the choice to sink or to swim.  Choose to swim!

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