Group Health Insurance

What is meant by the term "preexisting condition"?

In a group insurance policy, a preexisting medical condition is defined as a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within six months prior to the insured's enrollment under the plan. Insurance contracts may not cover these preexisting medical conditions for a period of time after you enroll in the plan.

Are there preexisting conditions that cannot be excluded from group coverage?

Yes. Pregnancy cannot be treated as a preexisting condition. If you're pregnant when you join your new group health plan your pregnancy must be covered. Genetic information may not be considered a preexisting condition if there is no specific diagnosis of a disease or medical problem related to the information.

My ex-spouse and I each have group health insurance coverage, insuring our children. Whose policy should pay first on claims submitted to both companies?

Generally benefits for the children are determined in the following order; first, the plan of the parent with custody of the children; second, the plan of the new spouse of the parent with custody of the children; third the plan of the parent not having custody of the children.

What if the divorce decree specifically names one of the parents responsible for the children's health care expenses?

In such a case, the plan of the responsible parent pays first. If the court decree states parents have joint custody and doesn't name one parent responsible for the children's health care expenses, or if the court decree states both parents are responsible for the children's health care expenses, but gives only one parent actual custody, the plan of the parent whose birthday falls earlier in the year pays first. If both parents have the same birthday, the plan that covered the parent longer, pays first.

My employer has told us that we will be going to a self-insured arrangement with our health insurance. What does this mean for me?

It means that your employer has established its own plan to help cover employees' health care expenses. Sometimes employers do this and have the health plan administered by an insurance company or other firm; but sometimes there is no outside administrator. With self-insured plans, certain federal laws may apply. You will not have any of the protection state insurance law provides because federal law preempts state jurisdiction over most self-insured plans through the Employee Retirement Insurance Security Act also known as ERISA.

I will be leaving my job in a couple of weeks and I am worried about my health insurance. Is there any way I can keep my group insurance coverage?

If you are leaving a job and not immediately going to work for an employer who offers group health insurance coverage, you may be able to continue your prior group coverage for up to 18 months. However, you will be responsible for the entire premium, both the portion you paid as an employee and the employer contribution as well.

I heard about a law that allows you to take your medical coverage with you when you change jobs. Is this true?

This is only partially true. You do not actually take your exact plan of health benefits with you, but you do get to "take the credit" for the time you were covered under your former plan to your new employer's plan. Under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Wisconsin insurance law, any preexisting condition waiting period in your new employer's group health benefit plan will be reduced by the amount of time you were covered by your prior employer's group health plan if you do not have a break in coverage longer than 62 days.

Who has continuation and conversion rights?

Under Wisconsin law, the right to continue group insurance coverage or to convert to an individual policy applies to: a former spouse whose coverage ends because of divorce or annulment; a group member who is no longer eligible for coverage under a group policy, as well as the covered spouse or dependents, except an employee who is fired for misconduct; and the covered spouse or dependent of a group member who dies. The federal COBRA law, which applies only to employers with 20 or more employees, also allows certain persons the right to continue group coverage.

Who is responsible for notifying people of their rights to continuation or conversion?

The employer is required to provide notice in the case of group coverage. If a couple is covered under an individual (not group) policy and coverage of one spouse ends because of divorce or annulment, the insurer is responsible for giving notice to the former spouse of the right to obtain his or her own individual policy.

How long does a former employee have to sign up for continuation of health insurance?

Under Wisconsin insurance law, the former employee must elect to continue the insurance and submit the premium to the employer within 30 days from the date of the employer's notice.

What happens if someone is not notified of his or her rights?

Group coverage continues until notice is given if the required premium continues to be paid. If coverage terminates, the aggrieved party may have a basis for a civil action against the employer or former spouse. Wisconsin insurance law does not make another party responsible for a terminated insured's medical expenses.

My job was terminated and my employer went out of business. Can I continue my group health insurance coverage?

Continuation rights are not available if no group policy exists. The right to convert to an individual policy providing reasonably similar benefits still applies.