In America, an estimated 133 million people suffer from one or multiple chronic illnesses, such as arthritis, heart disease, or hypertension. These types of health conditions are often referred to as “pre-existing conditions” by insurance companies.
Let’s look at how group health insurance handles pre-existing conditions for employees and how a benefits consultant can help you manage your group health plans effectively.
Understanding Pre-existing Conditions
Everyone gets sick occasionally, whether it’s the common cold or the flu. However, an illness or injury that is permanent, chronic, or recurring is generally referred to as a pre-existing condition. Examples of pre-existing conditions include diabetes, cancer, sleep apnea, and chronic obstructive pulmonary disease (COPD).
Pre-existing Conditions in the Context of Health Insurance
In health insurance, a pre-existing condition is any mental or physical condition that existed before a person enrolled or began receiving health insurance.
Some pre-existing conditions are less serious; the patient usually fully recovers over time, such as a broken leg. Others may be long-term and require ongoing treatment for months or years, such as Crohn’s disease or cystic fibrosis.
Legal Considerations and Regulations Related to Pre-existing Conditions
Before passing the Affordable Care Act (ACA), an insurance company would review a person’s enrollment application; if it was determined that the person had a pre-existing condition, the company could deny coverage or offer health benefits at an inflated rate.
Signed into law in 2010, the ACA made it illegal for health insurance companies to deny coverage, charge more for insurance, or limit benefits if you or a dependent had a pre-existing health condition.
However, if you enrolled in a health plan that started before 2010, you have a “grandfathered plan.” Grandfathered health plans are not legally required to cover pre-existing health conditions.
Group Health Insurance Plans and Pre-Existing Conditions
In the United States, most people under age 65 have health insurance directly through their employer or through an employed family member, such as a parent or spouse. Before enrolling in a group health insurance plan, it’s important to understand the coverage options and potential limitations a policyholder may encounter when using their benefits.
Coverage Options for Employees With Pre-existing Conditions
Employees with pre-existing conditions can enjoy comprehensive benefits under a range of plans, such as health maintenance organization (HMO), preferred provider organization (PPO), and point of service (POS) plans.
How claims are handled will depend on whether an employer offers fully insured plans or self-funded plans. With a fully insured plan, the employer contracts with an insurance company to provide employees with health coverage, including workers with pre-existing conditions. With a self-funded plan, the employer assumes the financial risk of providing employees with health coverage.
Limitations on Pre-existing Condition Exclusions
Pre-existing condition exclusions in group health insurance plans are subject to specific laws and regulations to protect employees with pre-existing conditions.
Both ACA and HIPAA regulations contain provisions that prohibit group health plans from denying coverage or imposing exclusion periods for employees with pre-existing conditions. In addition, the ACA limits the duration of exclusion periods to no more than 12 months.
Strategies for Managing Pre-existing Conditions in Group Health Plans
Effectively managing pre-existing conditions in group health plans requires a multifaceted approach that focuses on balancing quality care and cost control.
Employers must also take the necessary steps to ensure their coverage options comply with regulations prohibiting pre-existing condition exclusions, such as the ACA. By designing and implementing the right strategies, employers can create an inclusive environment that meets the healthcare needs of a diverse workforce.
Consulting With Benefits Consultants for Expert Guidance
When approaching the complex area of group health benefits, consulting with an experienced benefits consultant is essential. Benefits consultants are well-versed in group health insurance plans, including policies that provide comprehensive coverage to employees with pre-existing conditions. These consultants can also help streamline managing group health plans, saving employers valuable time and resources.
Implementing Proactive Health Management Programs
Managing pre-existing conditions in group health plans requires implementing a proactive health management program. With guidance from an expert benefits consultant, employers can conduct a comprehensive assessment of the workforce demographics, existing benefit offerings, and health risk factors to design a tailored program that meets the unique needs and preferences of the workforce.
Consultants can help employers identify and choose vendors or third-party providers to support the health management program. This may include disease management companies, wellness vendors, health coaches, and similar service providers.
Effectively Manage Your Group Health Plans With the Help of New City
New City Insurance has been helping organizations manage their group health plans since 2008. Speak with an experienced employee benefits consulting firm to see how we can help you build and implement plans that provide superior value to your organization.