Is Lymphedema a Preexisting Condition?

Introduction

HIPAA Making The Law Work For You

When changing jobs and/or health insurance coverage, a major concern for those with lymphedema is whether or not lymphedema will be managed as a preexisting condition and therefore there will be a wait before benefits of the new plan become effective.

The Federal law “Health Insurance Portability and Accountability Act of 1996,” commonly known as HIPAA, clearly states limits on the circumstances under which a preexisting condition exclusion may be applied.

HIPPA applies only to private sector employees. State, and local government employees should contact the Centers for Medicare and Medicaid Services at the U.S. Department of Health and Human Services about whether they have comparable protections.

Your Health History

One of the most important protections under HIPAA is that it helps those with preexisting conditions, such as lymphedema, get health coverage. In the past, some employers' group health plans limited, or even denied, coverage if a new employee had such a condition before enrolling in the plan. Under HIPAA, that is not allowed. If the plan generally provides coverage but denies benefits to you because you had a condition before your coverage began, then HIPAA applies.

How Recent Was Your Previous Insurance?

HIPAA provides that a plan may impose a "preexisting condition exclusion" only if there has been a lapse in your health care insurance coverage for more than 60 days. If there has been no lapse for more than 60 days in your health care insurance, no preexisting conditions can be applied.

If Your Coverage Gap was More Than 60 days

If there has been a gap of more than 60 days in your health care insurance coverage, then the following considerations apply:

• The exclusion relates to a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within the 6 month period ending on your enrollment date. The major question that might apply to you is, “Was treatment recommended, or did you receive treatment for your lymphedema within the 6 month period ending on your enrollment date?” If not, then, although the lymphedema was present, it cannot be counted as a preexisting condition.
• The preexisting condition exclusion can extends for no more than 12 months,or 18 months in the case of a late enrollee in the new plan, after the enrollment date.
• The preexisting condition exclusion period is reduced by the days of prior creditable coverage (if any, which is defined in HIPAA as most health coverage).
• The plan also must provide you with written notification of the existence and terms of any preexisting condition exclusion under the plan and of your rights to demonstrate prior creditable coverage.
• For an fuller explanation of HIPAA go to the HIPAA Making The Law Work For you website. Here you can print a copy of “Your Health Plan” or request that a copy be sent to you.
• HIPAA is complemented by state laws that, while similar to HIPAA, may offer more generous protections. You may want to contact your state insurance commissioner's office to ask about the law where you live. A good place to start is the Web site of the National Association of Insurance Commissioners.
• When you become eligible for coverage under Medicare, there are no exclusions for pre-existing conditions.

© LymphNotes.com 2009. This information does not replace the advice of a qualified health care professional.

Got a question or comment? Post in the 'Insurance, Medicare' forum.
Category: Insurance and Medicare Updated: 2009-11-13