I had a massive heart attack five months ago. Last month my husband lost his job (and our health insurance). Now he is employed again, with a different company and different insurance. This insurance will NOT cover my "preexisting condition" (my heart). I'm still in a wheelchair and also use a walker. How am I going to be able to see my cardiologist and neurologist and have future tests done if the insurance won't handle it? We can't afford the costs out-of-pocket. How do I get help in getting the treatment I need to get well?

Belle

The timing you describe indicates that federal law may require your new insurance plan to cover the pre-existing condition, or at least limit the time that it may be excluded from coverage. In 1996, Congress passed the Health Insurance Affordability and Accountability Act (HIPAA), the main purpose of which was to protect the insurability of millions of Americans. The law states that a person who maintains continuous coverage will need to satisfy a 12-month pre-existing condition exclusion period only once.
Here is how this works. When a person is first covered by an employer-sponsored plan, the plan can impose an exclusion for pre-existing conditions for 12 months. If the person continues to work for the same employer, all conditions will be covered after 12 months. If the employer changes health plans any time during that 12-month period, the enrollee, in effect, receives a credit against the 12-month exclusion in the new plan for each month of coverage on the old plan. Those employees covered for 12 or more months under the old plan have satisfied their exclusion.

The same holds true when a person changes jobs, even if there is a small gap in coverage. Again, a person receives a "credit" for each month of coverage, which is applied to the new employer's plan. If a person has 12 or more months of coverage, the new employer's plan cannot impose a new exclusionary period. The only time that the exclusion period can be re-applied is when the gap in coverage was 63 or more days. Even then, the exclusion period may not exceed 12 months. So in the case described above, given a gap in coverage of fewer than 63 days, the 12 month exclusion period is reduced by the number of months of coverage under the old plan.

If your coverage gap was more than 63 days, you may have to satisfy another exclusion period. In any case, it cannot exceed 12 months. After that, your insurance will cover all pre-existing conditions according to the provisions of the benefit plan.

When a person leaves a job with health benefits, the law requires the insurance company to issue a certificate proving the person had coverage, and for how long. The new insurance company uses this information to determine the applicability of a pre-existing condition exclusion. If you believe that you have satisfied your exclusion, you may need to ask for a certificate from the former employer plan and forward this to the new plan. Contact the new employer's benefit manager to find out why your condition is being excluded and how best to address this situation.

There is another employee benefit that may come into the picture. Employers with more than 20 employees (sometimes less, depending on state law) must offer COBRA continuation coverage to employees who leave or are terminated. The employees must pay for the coverage themselves, but at least they have the opportunity to continue their insurance and protect their insurability. If you think you were eligible for this coverage but the employer did not offer it to you, call the employer's benefit manager to find out why. This is your right, and employers must comply with this law.