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pnwmom

(108,925 posts)
Fri Apr 26, 2013, 07:26 PM Apr 2013

Pre-existing condition -- does anybody know . . . ?

I'm trying to help a young woman figure out her coverage, which she has had for a couple months. She has a gap in coverage, so her new insurer won't cover her for any pre-existing condition for 9 months. (At which point Obamacare will make this issue go away, but she needs coverage now.)

I tried to get the answer from the insurer, but got a very confusing explanation. It almost sounded like a newly sprained ankle could be considered a pre-existing condition.

What is a pre-existing condition exactly? Is it only a condition that you actually received a diagnosis or treatment of BEFORE your current coverage? Or can it include conditions that are diagnosed AFTER your new coverage starts?

The young woman needs mental health counseling. She has never been diagnosed with PTSD, but I think she has it, and I think it's because of something that happened years ago. Are they going to say that it is a preexisting condition because it was caused by an earlier trauma? Or will it not be pre-existing, because she never had it diagnosed or sought treatment for it before?

29 replies = new reply since forum marked as read
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Pre-existing condition -- does anybody know . . . ? (Original Post) pnwmom Apr 2013 OP
Basically, it's any condition -- diagnosed or not -- that you had before you had insurance coverage unrepentant progress Apr 2013 #1
Thanks for the link, unrepentant progress. pnwmom Apr 2013 #3
I know unrepentant progress Apr 2013 #5
and the blame for this falls squarely at the Democrats. If you lost your still_one Apr 2013 #6
Why blame the Democrats because the Republicans filibustered it? pnwmom Apr 2013 #16
they could have, and still can change those rules anytime, with an up or down vote. Everything I still_one Apr 2013 #18
It's anything the insurance company wants Glitterati Apr 2013 #2
This is one of the largest disgraces of the ACA, and damn the democrats who allowed it to happen still_one Apr 2013 #4
Let's be fair, preexisting exclusions were around long before Obama, and Hoyt Apr 2013 #8
Let's be fair, they could have NOT backloaded it into the healthcare plan, and to pour salt into the still_one Apr 2013 #9
There are folks right here on DU who have coverage right now who didn't before. Hoyt Apr 2013 #10
and that is good, but they also didn't not help a lot of other people who they should have still_one Apr 2013 #11
Why are you so angry with Obama for a situation that was beyond his control? pnwmom Apr 2013 #12
First of all I blamed the Democrats in the Senate mostly if you read my comments. repukes were NOT still_one Apr 2013 #13
How do you know there was a better option that could get 60 votes? pnwmom Apr 2013 #14
I stated if they wanted to they could have changed the filibuster rules. This legislation was still_one Apr 2013 #21
Hindsight is wonderful. They would have had to have changed the rules pnwmom Apr 2013 #22
at least what I have come to understand, may be wrong, the filibuster rules could be changed anytime still_one Apr 2013 #24
I don't like any of that, either, though I'm glad for all the children who immediately pnwmom Apr 2013 #25
Because the repugs would never have voted for anything, remember this plan was essentially the still_one Apr 2013 #27
So the blame falls squarely on the DEMS because the Republicans are worse. pnwmom Apr 2013 #28
That clause is horrible. In the meantime, see if you can help her get counseling through the County Hekate Apr 2013 #7
Thanks, Hekate. pnwmom Apr 2013 #23
Don't forget to look for a Federally Qualified Health Clinic in your area for her Recursion Apr 2013 #15
THANK YOU! I didn't think of this at all. pnwmom Apr 2013 #17
Depends on the state. Nye Bevan Apr 2013 #19
My wife and I are uninsurable. hunter Apr 2013 #20
If you have ever had a cold, all colds are pre-existing conditions. kestrel91316 Apr 2013 #26
If the insurance does not want to pay they won't - period. KentuckyWoman Apr 2013 #29

still_one

(91,946 posts)
6. and the blame for this falls squarely at the Democrats. If you lost your
Fri Apr 26, 2013, 07:48 PM
Apr 2013

insurance, you have to wait 6 months before you can have the interium pre existing coverage

If you had coverage and lost it through a job, cobra would kick in but that isn't cheap

pnwmom

(108,925 posts)
16. Why blame the Democrats because the Republicans filibustered it?
Fri Apr 26, 2013, 09:07 PM
Apr 2013

The Democrats didn't have 60 votes. They couldn't have gotten anything stronger past the Senate.

still_one

(91,946 posts)
18. they could have, and still can change those rules anytime, with an up or down vote. Everything I
Fri Apr 26, 2013, 09:12 PM
Apr 2013

have read, their is NO requirement that they only have one chance to do it. The fact is they did not want, and do not want to get rid of the filibuster

http://en.wikipedia.org/wiki/United_States_v._Ballin

Of course, lets not rock the boat.

 

Glitterati

(3,182 posts)
2. It's anything the insurance company wants
Fri Apr 26, 2013, 07:37 PM
Apr 2013

My son was born premature with asthma. His insurance labeled it pre-existing when he was 23 yrs. old.

If they want to deny coverage, they'll label it pre-existing. And you can damned well be assured mental health issues are gonna be pre-existing.

still_one

(91,946 posts)
4. This is one of the largest disgraces of the ACA, and damn the democrats who allowed it to happen
Fri Apr 26, 2013, 07:42 PM
Apr 2013

It does not take effect until 2014, so when the bill was written people with serious pre-existing conditions needed to wait 4 years in order to get coverage

If her income is at poverty level she could qualify for Medicaid or medical in California

Otherwise if someone needs immediate treatment for a pre-existing condition, and they are not at poverty level income you either die or dissolve all your assets to pay for it until you are at poverty level

I will never forgive the Democrats for allowing this backload into the ACA

 

Hoyt

(54,770 posts)
8. Let's be fair, preexisting exclusions were around long before Obama, and
Fri Apr 26, 2013, 08:22 PM
Apr 2013

The ACA did set up a fund for folks with preexisting conditions, and ends that crud in 8 months. It might not be perfect, but it's better than what we had before.

still_one

(91,946 posts)
9. Let's be fair, they could have NOT backloaded it into the healthcare plan, and to pour salt into the
Fri Apr 26, 2013, 08:33 PM
Apr 2013

wound, as an "bridge", if you lost your insurance, you had to be without 6 months before you could not be excluded for pre-existing conditions.

I was very lucky when I was laid off last year, and found a job, so I only had to be under COBRA for a short period of time before I was covered by my new company, but a lot of people with pre-existing conditions were not that fortunate, and "fund" you speak of did not kick in until you were without coverage for 6 months

How can anyone justify that except to say, and I believe this, they wanted those people with very serious pre-existing conditions to die, or go broke and lose everything

I am being more than fair. They could have done something great and instead did something half-assed, and this was NOT because of the repukes, because they did not vote for it anyway, we had the majority, and the Democratic party, especially those in the Senate dropped the ball.

Gee, a person with a heart condition, wait 6 months, if you have a heart attack before then, we will bankrupt you.

still_one

(91,946 posts)
11. and that is good, but they also didn't not help a lot of other people who they should have
Fri Apr 26, 2013, 08:46 PM
Apr 2013

and I am sorry their is no excuse for a backloaded pre-exsiting condition clause. In fact there is no justification for not having a public option.

The lobbyists and insurance companies won, the country lost.

We are going to have to agree to disagree, I was almost in the boat where if I wanted insurance I would be paying 750 dollars a month for COBRA. How would I afford that again? sell my assets. FDR would have NEVER let that happen

pnwmom

(108,925 posts)
12. Why are you so angry with Obama for a situation that was beyond his control?
Fri Apr 26, 2013, 08:52 PM
Apr 2013

He couldn't force the Republicans to accept a better deal. Neither could Pelosi or Reed. There had to be a compromise, unfortunately. There was never a single day when the Democrats had 60 votes. Lieberman wasn't a Democrat when Obama's term began, and then Kennedy died a few months later and the situation went from bad to worse.

still_one

(91,946 posts)
13. First of all I blamed the Democrats in the Senate mostly if you read my comments. repukes were NOT
Fri Apr 26, 2013, 09:02 PM
Apr 2013

even in the picture, they did not vote for it, it was the Democrats who made this what it was, and wrote the darn thing.

and I am extremely angry because they excluded those advocates who wanted a public option out of the discussions. This was bought and paid for by the special interest groups. Yes, Sanders and other good people voted for it, because it was "better than what was before", where 40 million uninsured would be covered, but it was not the best they could do, and that is the disgrace. Is that all the Democratic party can do, mediocre legislation.

and by the way, you never said it, but I am NOT an Obama hater, but the President could have pushed the message for healthcare like he did for sane gun legislation this time.



pnwmom

(108,925 posts)
14. How do you know there was a better option that could get 60 votes?
Fri Apr 26, 2013, 09:04 PM
Apr 2013

Because that's the bottom line. 60 votes in the Senate or nothing would have passed.

still_one

(91,946 posts)
21. I stated if they wanted to they could have changed the filibuster rules. This legislation was
Fri Apr 26, 2013, 09:17 PM
Apr 2013

bought and paid for by the insurance companies

We will see in the next two years just how good or bad it is. No question it will help the uninsured, and that is good, but it may hurt the lower middle class, and maybe the middle class badly, if the premiums are too high

http://en.wikipedia.org/wiki/Nuclear_option



pnwmom

(108,925 posts)
22. Hindsight is wonderful. They would have had to have changed the rules
Fri Apr 26, 2013, 09:32 PM
Apr 2013

before Obama took office. Those rules were already in place by the time this bill was being negotiated.

No Senate minority in history had ever used the filibuster the way it has been used against Obama -- so the Democrats wouldn't have known that it would be necessary. You're also forgetting how much of a difference it made when Kennedy died. Through the sheer force of his personality, he could probably have twisted another few arms and gotten something better through. But when he died, the chances of the public option died too.

still_one

(91,946 posts)
24. at least what I have come to understand, may be wrong, the filibuster rules could be changed anytime
Fri Apr 26, 2013, 10:15 PM
Apr 2013

Last edited Sat Apr 27, 2013, 03:46 AM - Edit history (1)

However, let's assume I am wrong, which I could be. At the time what bothered me the most was when the talks for healthcare started they did everything to exclude those advocates for a public option a seat at the table. Even before they started, they already caved into the special interests.

The next criticism I had was they complicated it with a tremendous amount of rules, such as back-loading a lot of BASIC things, such as pre-existing conditions, and waiting 6 months of having no insurance before you could be eligible for the bridge. What ethical person would right that into the 1200 pages of legislation?

After it was written they did not even market it. There are polls out today that indicate people do not even know what benefits they are entitled to under it. There is no excuse for that.

and the last point, in 2010 most of Congress ran away from the ACA, what does that imply?

pnwmom

(108,925 posts)
25. I don't like any of that, either, though I'm glad for all the children who immediately
Fri Apr 26, 2013, 10:29 PM
Apr 2013

benefited from the no-preexisting-conditions-for-kids clause, and all the cancer victims who couldn't be kicked off their insurance, and all the people who don't have to worry about annual or lifetime limits anymore.

And I'm still wondering why you put the blame "squarely on the Democrats" when the Republicans wanted no health care bill to pass at all? And did everything they could even to fight this one, which basically replicated the Republican plan in Massachusetts?

still_one

(91,946 posts)
27. Because the repugs would never have voted for anything, remember this plan was essentially the
Sat Apr 27, 2013, 03:52 AM
Apr 2013

republican plan from romney. It was the Democrats who did not even try to have some of the most desired features. When they give up on a public option and other things before negotiations even started, that send a very strong message to me where they are coming from.

Where is the passion to fight for healthcare.

Believe I hope it is affordable, and helps people, and it will help some, but it should have helped everyone

pnwmom

(108,925 posts)
28. So the blame falls squarely on the DEMS because the Republicans are worse.
Sat Apr 27, 2013, 05:02 AM
Apr 2013

That makes a lot of sense.



When Ted Kennedy died, everything changed. The only chance we would have had for a public option is if he had lived. No one else had the ability he did -- and even he might have failed.

The Rethugs have been fighting Obama tooth and nail ever since he took office, with an unprecedented use of the filibuster. I've been watching Presidents and Congresses for 40 years and I've never seen a Congress behave the way this one has toward Obama. You're fooling yourself if you think that if Obama had been nastier or pushier he would have achieved more. These people decided on a strategy 5 years ago and that was to refuse to cooperate with anything he did, so that people would blame him and they would be back in office. It didn't work in 2012, but they'll continue in this manner till it does.

Hekate

(90,189 posts)
7. That clause is horrible. In the meantime, see if you can help her get counseling through the County
Fri Apr 26, 2013, 08:06 PM
Apr 2013

... mental health system, if there is anything along that line.

Also, ask around to see who has a sliding scale of fees -- some practitioners will take a few on, but you have to ask. Therapists with a Master's Degree (and 3,000 hours of indentured servitude under their belts) cost less than Psychiatrists with an M.D. (and the associated debt from medical school). However, practitioners with an M.A. or Ph.D. cannot prescribe medication. On the other hand, when my therapist finally realized that a pharmaceutical might benefit me, she referred me to a psychiatrist she knew who wasn't taking on new patients but agreed to treat me long enough to prescribe an antidepressant and stick around to make sure it was the right dose. Over time I had my internist take over writing the prescription, since it was a fait accompli.

I wish you and your friend all the best. I don't think I ever bothered trying to get my insurance carrier to cover any of my expenses -- the reimbursement would have been pathetic and the loss of privacy not worth it to me. I did, however, work on the sliding scale of fees thing -- and saved a lot of money that way.

Hekate

Recursion

(56,582 posts)
15. Don't forget to look for a Federally Qualified Health Clinic in your area for her
Fri Apr 26, 2013, 09:05 PM
Apr 2013

They are open to all and charge on a sliding scale. This is one of the best things in the law, and it's the reason Bernie Sanders voted for it:

http://findahealthcenter.hrsa.gov/Search_HCC.aspx

Nye Bevan

(25,406 posts)
19. Depends on the state.
Fri Apr 26, 2013, 09:13 PM
Apr 2013
Most insurance companies use one of two definitions to identify such conditions. Under the "objective standard" definition, a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan. Under the broader, "prudent person" definition, a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.[5]

Which definition may be used is sometimes regulated by state laws. Some states require insurance companies to use the objective standard, while others require the prudent person standard. Currently, 10 states do not specify either definition, 21 require the "prudent person" standard, and 18 require the "objective" standard, according to www.statehealthfacts.org.


http://en.wikipedia.org/wiki/Pre-existing_condition

hunter

(38,264 posts)
20. My wife and I are uninsurable.
Fri Apr 26, 2013, 09:15 PM
Apr 2013

That's why our credit rating is in the toilet.

My wife has health insurance through her work now, but it's not very good. Mental health coverage is especially bad. Our kids' colleges required us to buy supplemental student health insurance to make up for what our family insurance lacked. We've gone through periods of no health insurance for my wife and I, just insurance for our kids, or inadequate state insurance. We've run COBRAs out to the very end.

Medical bills we couldn't pay wiped us out.

When my wife and I were married we both had excellent UNION negotiated insurance. Those days are gone.

If we lived in a real first world nation, say like Canada or most anywhere in Europe, my wife and I would be doing okay financially.

It's appalling the USA has no national single payer health care system. Random shit-falling-out-of-the-sky health problems or bad accidents can happen to anyone.

I don't know what to say. I know what resources are available in my own community, but they are entirely local and overburdened.

 

kestrel91316

(51,666 posts)
26. If you have ever had a cold, all colds are pre-existing conditions.
Sat Apr 27, 2013, 01:19 AM
Apr 2013

If you have ever had a skin problem, all skin problems are pre-existing conditions.

If you have ever had a bladder infection, all UTIs are a pre-existing condition.

If you have ever had ANY kind of heart problem, all heart problems, even if completely unrelated, are pre-existing conditions.

If you have been uninsured for years, in excellent health and so haven't been to a doctor in years, you are assumed to have a pre-existing condition that you are hiding if you try to obtain insurance.

Do you get how it works now, and why Obamacare has insurance companies and their fawning acolytes so upset??

KentuckyWoman

(6,666 posts)
29. If the insurance does not want to pay they won't - period.
Sat Apr 27, 2013, 08:19 AM
Apr 2013

There are so many loopholes and vague definitions built into the law so that they can avoid paying. Larger group buyers have more clout in getting things paid than individual policies but all of them have coverage issues.

Most communities have mental health programs that can step in and help but most are overburdened. Around here the United Way or Salvation Army is a one stop shop for information on community services whether it be medical care or help paying the light bill.

If her condition is critical enough that she's a real danger to herself or others most states allow the ER doctor to admit an indigent mental health patient for up to 72 hrs as a life saving measure but patients can be held until the psychiatric team decides the life and death danger has passed. This would get her "in the system" but facilities are generally so bad I would only recommend that if it's really a life and death situation.

I wish you and your friend the best. The mental health system in this country is far worse than the physical health system.

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