According to the Department of Labor' HIPAA Act of 1996, "... HIPAA prohibits plans from applying a preexisting condition exclusion to pregnancy, genetic information, and certain children".
Info from Dept. of Labor website: www.dol.gov/ebsa/faqs/faq_consumer_hipaa.HTML
the laws that govern group and individual health plans are a little different when it comes to pre-existing conditions, and are enforced or regulated by the state department of insurance in the state where you live.
individual plans, almost without exception, will not take on a pregnant applicant, or even a male who is looking for a health plan if he's fathered a child that hasn't been born yet.
group plans are much more likely to accept a pregnant employee, or the spouse of a pregnant woman, on their plan after the employer's probation period is over. however, it's possible if the pregnancy is beyond the first trimester to encounter problems getting accepted. the fastest way to get the true in this situation is to find out what the employer's probation period is (90 days or whatever), and also ask the benefits administrator at the company to call the health insurance carrier and ask them directly. in Texas, by law, pregnancy is supposed to be covered like any other pre-existing condition on a group plan. however, if pre-ex conditions have a waiting period of 12 months and baby is due in 6 months, it doesn't help a new employee much.
finally, every state has an individual health insurance plan that is sponsored by the state department, for persons with pre-existing that can't get covered or accepted anywhere. do a Google search for "[your state] department of insurance" and the link for the site will come up. contact them or review the website and look for the 'risk pool' plan. in Texas, blue cross blue shield is the provider. every state is difference. this individual policy provides coverage for persons with terminal illness, pregnancy, and anything else other insurance companies often decline or charge a fortune to cover. the premiums are about 1.25 - 1.5 times more than health insurance for the same applicant would be with a company that does not cover pre-existing conditions, but the coverage is guaranteed. in other words, you can't be declined.
this works perfectly if you already have health insurance that doesn't cover maternity. the risk pool plan will have at least a 12 month waiting period for pre-ex, like group health plans do. if you have had your old health insurance for any period of time - especially for twelve months already - you get credit for that coverage and your waiting period for pre-ex is eliminated on the new plan. if you had coverage for six months, the risk pool would give you six months of credit off the pre-ex waiting period. if your baby's due in 8 months, it will work because you only have to wait six months for the pre-ex part of the coverage to be effective. if your baby's due in 2 months, your pre-ex period won't be over yet and it the pregnancy won't be covered.
so what do you do if the s above don't work for you ...?
in a worse case scenario, you can approach your obstetrician and negotiate a price for a package deal of nine months of prenatal care and baby delivery. the cost would be at least $2,500-3,500; for c-sec, $5,000-7,000. your cash offer should be 50% of whatever the doctor charges insurance companies for the same service. offer monthly payments with the last one due on the baby's due date. you can negotiate the hospital bill for a package deal for an overnight stay the same way.
call each medical care provider (ob and the hospital) to get the charge they send to insurance companies for the services you need before you let on you need to negotiate your bill. if you can, pay the hospital installments over the nine months during the pregnancy and they'll be more likely to agree to the arrangement. collecting money for medical services after the care has been rendered is really difficult, so many medical providers don't like to negotiate at all. don't be discouraged. good ob docs and hospitals do this everyday, but it's not in the grapevine for the public to know. it's easy to panic if you're expecting and don't have maternity. instill the idea in your mind that everything's negotiable, and trudge ahead with finding a doctor and hospital you like. your determination will show and help you during negotiations. it's also a good persuasion tool to write your arrangement on paper when you present it to a medical care provider to show how serious you are.
if you have any other questions, please feel free to email me. I'm a Group One licensed insurance agent. i sell health, life, dental, annuities and am just about to publish a book to explain insurance better for consumers and help them save 3-4 figures a year on health insurance premiums.
to the extent i can help any more i'd be glad to.
NOT ALWAYS! Some plans may have a pre x clause that includes everything EXCEPT pregnancy.
No. According to the HIPAA regulations of 1996, pregnancy can NEVER (no matter what state or what insurance company) be considered a pre-existing condition in group health plans.
For reference: http://cms.hhs.gov/hipaa/online/group/family/Pregnancy_content.asp?record=480021
The honest is sometimes. It all depends on whether or not the organization offering insurance has opted for HIPAA regulated insurance. In my own personal account I was denied coverage for my pregnant wife when switching from one group insurance from the private sector to a group insurance in the county government sector. So, you see that it is not always excluded from being pre-existing.
Pregnancy is not a pre-existing condition when enrolling in a group (employee benefits) plan. That is not the whole answer to the question. It needs to be determined if your question is about group or individual insurance? It is true that pregnancy is not considered a pre-existing condition if you are going from one HMO to another. But it is a different story when when you go from private coverage to an HMO, or if you did not have insurance previously then tried to go to an HMO. HIPPA (federal law) requires that when going from one job to another, and also changing HMO, then the new HMO can not bar you from coverage. There is however no federal protection if you did not have coverage before. **** It depends on when you got you medical insurance. I have been told by my insurance that it could be if you got prego before you got your insurance. It all depends on the company you work for or where you insurance is through. ****
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