Medicare supplement plans and preexisting conditions?

[ReTiReD51]

Question?

In my state United Health a few years back allowed its members to switch from plan F to any of their other lettered plans no questions asked any time throughout the year. Then with 4 months left to go before plan F was phased out for new enrollees UH started requiring you to answer questions pertaining to any possibilities you might have a preexisting condition which might prevent you from switching from their plan F to any other of their lettered plans.

My question is what constitutes a preexisting condition?

If I was taking a statin to help lower my cholesterol levels to reduce my risk of a heart attack with plan F, would that be considered a preexisting condition in being accepted for another UH supplement plan?

What about a pill to reduce inflammation symptoms (arthritis) and improve quality of life? A preexisting condition?

Hopefully you get the gist of what I’m asking, what constitutes a preexisting condition?

And not to pick on UH because many other insurance carries refused from the beginning to allow anyone to switch plans without answering preexisting condition questions.

[somarco]

@ReTiReD51 in SOME states UHC still allows movement from one plan to another without underwriting. I have no idea which states require underwriting, which do not.

The underwriting questions on the application set the parameters. Most carrier apps ask about specific conditions in the last 12, 24, 36, 48 or 60 months.

Anthem used to ask if you had EVER had this or that, but they came to their senses a few years ago and set lookback time limits.

I have no idea about the UHC wording.

If your state requires underwriting and you don't like the UHC wording, look at other carriers.

Just saying . . .

[ReTiReD51]

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Since I didn’t get that far in requesting an application for any underwriting questions, I didn’t know about the lookback time limits. It is a little more detailed and allows the insurance carrier to carefully determine whether you have a preexisting health condition or not.

I wish all states would coordinate together and not require underwriting on the Medigap plans like they don’t require underwriting on Medicare Advantage plans.

Thanks for your help!

[somarco]

@ReTiReD51 I wish all states would coordinate together and not require underwriting on the Medigap plans like they don’t require underwriting on Medicare Advantage plans.

Medigap policies are regulated at the state level.

Advantage at the federal level - by CMS

 It is a little more detailed and allows the insurance carrier to carefully determine whether you have a preexisting health condition or not.

Most folks have SOME KIND of pre-existing condition. Some are serious, chronic or expensive to treat.

I talk to folks almost weekly. In the 65+ market it is extremely rare for someone to be in "perfect health", so most have a p-x condition.

The majority can make it through underwriting.

Of course I suspect a number of folks with truly serious conditions never call because they know they will be denied.

Instead of worrying if the carrier is going to like you or not, submit an application and see what happens. The rumors about being "red flagged" because of something in your file is based on ignorance of how these things work.

If you apply, same carrier or different one, and are rejected you keep what you have and move forward. No harm.

BTW, the screening is not just for things diagnosed and treated. The carrier also wants to know about scheduled exams, tests or procedures that have not been completed.

They can also apply the "prudent man" rule and investigate claims made up to 2 years after the policy is issued and seek to determine if you were willfully hiding information on your application. If they feel you have been misleading they can cancel your policy.

[GailL1]

So it is important NOT to cancel the old Medigap before you are assured that you have the new one in place. 

Might one have to pay (2) premiums in one monyh - the old one and the new one and then work on getting one or the other payment back once you are assured you know which one you are getting or keeping.

I guess you have to wait until you have any new policy in hand before cancelling the old one just to make sure.

[GailL1]

Good to hear from you again, @ReTiReD51 - Staying out of trouble, I hope.😉

A preexisting condition is ANY medical condition for which you have EVER received treatment or diagnosis.  That covers illnesses (cured or not), injuries (cured or not especially if it involved surgery with implantation of something to rectify the condition) and chronic conditions.

Questions asked usually involve the word "EVER".  That covers lots of time ground.

Yes taking a statin (treatment) for lowering your cholesterol level is indication of a chronic conditions - High Cholesterol.  Yes, taking an anti-inflammatory (treatment) to help arthritis pain and/or inflammation is an indication of a chronic condition - arthritis.  This also includes

What might not indicate a preexisting condition is taking a baby aspirin daily as a PREVENTATIVE measure, as an example.

[ReTiReD51]

@gail1

Myself and a couple of friends decided after dragging our feet for several months that we wanted to change our plan F to plan G for the $savings.  Well we waited to long and Insurance companies started requiring you to answer preexisting condition questions to switch from plan F to plan G. I don’t know if all states allow insurance companies to do this but it’s legal in Ohio.

What we learned was we could be required to wait for coverage to begin, 6 months to a year, for a questionable preexisting condition. As long as we MEET? other eligibility requirements.

We concluded that it was too much of a gamble. We were fortunate to find an Insurance company that did allow us to move from our then current plan F to their plan G without any questions asked about health. Much like a Guaranteed Issue back in the day when we were sweet 65. They only allowed new enrollees no questions asked just for 2019.

If I understand correctly and depending on your state, it can be a difficult problem if people beyond the guaranteed issue year in your life want to change their supplement plan F to another letter plan. Be cautious.

[GailL1]

Officially, Medicare only regulates some guarantee issue periods for Medigap plans plus basic plan designs of each of the alphabet titled plans - pass those major things they don't do too much regulation at the Fed level.

Medigap is not actually a part of Medicare - it is private insurance offering an option only for those who want this "GAP" coverage and can pay for it in those monthly installments.    So as much of our insurance coverage of various types - states may issue other rules of coverage over and above the guarantee issue periods and circumstances issued by Medicare.

Yes, in many states there could be a waiting period for preexisting conditions if you have the right to switch plans at all because in some states they can just deny new (switching) coverage if there are preexisting conditions.  They could also charge a person a lot more in monthly premiums under these circumstances.  Up to the states and the insurer.

The states can set their rules but then the insurers can vary from one to another in how they work within a state -

Course then in other states, they may give a date upon which one can change Medigap plans without underwriting - like California's Birthday Rule.

The ACA did NOTHING about this type of preexisting rules because it really isn't a full health insurance policy - it is just "GAP" insurance.  Traditional Medicare is the actual health insurance coverage and a Medigap policy just fills in the gaps in out of pocket cost.

This is one of the reasons why we have seen growth in the Medicare Advantage program.

[ReTiReD51]

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I didn’t know why the ACA didn’t do anything about the preexisting rules when it came to Medigap plans. Makes sense because Medigap does just fill in the 20% gap.

I never hear complaints about Medicare supplement plans, but hear plenty of complaints about Medicare Advantage plans, high deductibles and copays.

As I’ve said in the past you’re a very knowledgeable individual about the Medicare program.

Thanks for your help!

[GailL1]

You are welcome - why not go ahead and try to get another Medigap plan - just don't drop the one you have now until you have the new policy IN YOUR HANDS.  That might mean that you pay for (2) in the same month (old/new) and then recoup $$$ from whicher one later that you don't take or keep.(new/old)

I mean all they can say is NO or quote you a higher premium.

Personally, I would pay any good-faith premium for a new Medigap choice on a credit card so that if you decide that the final premium amt is too high or they want to exclude some condition for a while - you can refuse to accept their terms, stick with your current Medigap and make sure you can get your good faith money back ASAP -

somarco may not agree with my direction here - don't know, maybe he will comment - but hey, all fair in love and war.  😁

[somarco]

@ReTiReD51 Obamacare dealt with primary payers, not secondary.

They did not address underwriting for dental, vision, hospital indemnity or cancer insurance.

Likewise, Medicare supplement plans are secondary payers and were left out of the legislation.

Medicare supplement plans already have national GI (guaranteed issue) guidelines.

Additionally, some states have "birthday" or "anniversary" rules that allow policyholders to change plans under certain conditions and not be subject to underwriting. A few states require ALL Medigap carriers to issue plans without underwriting. FWIW, the rates in those states are quite high compared to neighboring states. 

At least one state (and maybe a few more) have carriers of last resort that will take anyone, regardless of health.

Underwriting is what helps to keep coverage affordable.

The "Affordable" Care Act did nothing to make health insurance affordable.

[ReTiReD51]

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"The "Affordable" Care Act did nothing to make health insurance affordable."

Many people did have their premiums rise but the insurance industry was required to cover people with preexisting conditions and required to spend at least 80 percent of their insurance premiums on medical care and improvements.

The ACA legislation prevented the Insurance industry from establishing a preset dollar limit on the coverage they provided to an individual consumer. They also covered many screenings and preventive services with low or no cost copays and deductibles, lowered Medicare part D prescription drug plans and proposed to eliminate the doughnut hole.

Obamacare was designed to prevent the Insurance industry from driving up patient cost and limiting patient care. Plus, healthier Americans will lead to lower healthcare cost over time. Good for everyone!

[somarco]

@ReTiReD51 insurance industry was required to cover people with preexisting conditions and required to spend at least 80 percent of their insurance premiums on medical care and improvements.

Carriers were already running 80% or higher loss ratio's.

Nothing really changed, except more reporting to the government and increased admin costs.

Most folks did not get "refunds" under the new formula. Some that did received $200 or less. The cost to the carrier to calculate LR's and cut checks far exceeded the benefit to the policyholders. The few that did get refunds only got them the first year.

covered many screenings and preventive services with low or no cost copays and deductibles, lowered Medicare part D prescription drug plans and proposed to eliminate the doughnut hole.

Oh boy . . .

Preventive @ low/no cost = premium rates increased to cover the "cost" plus increased utilization. There are no free lunches.

Lowered Part D - Seriously? Some premiums were lowered but offset by higher deductibles and copay's. Over the last 10 years most premiums have increased but the REAL cost of coverage has increased by double digits. Generic copay's are so ridiculously high for most folks that they are better off treating their PDP as catastrophic coverage only and using a discount like GoodRx for generics. Also GoodRx gives true discounts for 90 day fills on many generics while most PDP 90 day fills have no savings.

Eliminate the donut hole - The donut hole did not go away even when accelerated under Trump. It is still there.

Optional reading assignment

https://q1medicare.com/q1group/MedicareAdvantagePartDQA/FAQ.php?faq=Did-the-Coverage-Gap-or-Donut-Ho...

Obamacare was designed to prevent the Insurance industry from driving up patient cost and limiting patient care. 

That was the sales pitch. Quite effective, eh?

Neither of those came true and the insurance industry never limited medically necessary care.

More optional reading assignment

https://www.forbes.com/sites/theapothecary/2014/11/10/aca-architect-the-stupidity-of-the-american-vo...

When over 90% of carriers bailed on the under 65 market no one gained.

ACA legislation prevented the Insurance industry from establishing a preset dollar limit on the coverage they provided to an individual consumer. 

This only impacted indemnity plans which were not true major medical insurance. The carriers that wrote indemnity plans found a loophole (what a shock!) and continued writing these plans as if nothing happened.

[ReTiReD51]

@somarco “The carriers that wrote indemnity plans found a loophole (what a shock!) and continued writing these plans as if nothing happened.”

Proof that more congressional action is required to strengthen and expand the ACA.

And to reverse the many changes implemented by the current administration to undermine the ACA.

1.Let’s extend the health insurance financial subsidies to more income brackets.
2. Limit the sale of those individual market plans that don’t comply with ACA regulations        that you referenced above. 
3. Develop a public insurance plan.

It’s necessary to reform our healthcare system to control healthcare costs and lower healthcare insurance premiums, deductibles and copays because it’s not sustainable into the future.

Before the ACA the last time someone tried to reform our healthcare-system was 1993 the “Clinton healthcare plan”. The opposition was fierce like it was for Obamacare. And still in between and since there are Politian’s who object to any kind of reform and do absolutely nothing but carp about others attempts to reform our system so every American citizen can have affordable healthcare.

The ACA is not perfect but we should demand our elected officials sit down together and find middle ground to improve it.

A reading assignment for you, check out the numerous articles about the ACA on this very website. Your sentiments about the ACA couldn’t be anymore contradictory than theirs.

[somarco]

@ReTiReD51 I certainly understand your right to your own opinions, but as one who has worked in the health insurance industry for 45 years I believe I know a bit about what works and what does not. Government regulation essentially killed the insurance industry by removing risk evaluation and pricing. What is needed is LESS regulation, not more.

Expanding Medicaid, which was the real underlying intention of Obamacare, was likewise a failure that has contributed to fewer hospitals and less access to health care.

My degree in economics also tells me that subsidized health insurance is a great idea until the system runs out of money and collapses under its' own weight.

Paraphrasing PM Thatcher, socialism is great until you run out of other people's money.

[ReTiReD51]

@somarco 

The problem is that you’re viewing healthcare reform through your filter of 45 years working in the health insurance industry. In that if you had less regulation the company CEO could have made millions of dollars more in compensation.

When someone refers to healthcare reform as “socialism” it’s because the people’s tax money is being used in ways that would help “everyone”. But when hundreds of millions of dollars of the people’s tax money is given to corporations in lucrative government contracts it’s called capitalism.

If you step back, and try reexamining the ACA efforts to improve our healthcare system without viewing it through that 45-year-old filter you’ll see Obamacare makes more sense than not doing anything at all.

[GailL1]

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@somarco wrote:

Underwriting is what helps to keep coverage affordable.

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Like  those less than 65 years old who are on Medicare (disability) but without (affordable, if any) access to a Medigap plan - of course, this is to keep Medigap plans more affordable. 

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@somarco wrote:
The "Affordable" Care Act did nothing to make health insurance affordable.

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Sure didn't and it didn't fix the problem of people being UNDERinsured either.

BTW - there is a post on the caregiving forum about somebody that is involved with claim denial and rescission - can you see if you can add anything to that conversation - it is actually on the wrong board - not Medicare - sounds like a short term policy that was accepted without understanding.  TIA