Affordable Care: Some plans still don’t cover pre-existing conditions

“I am 24 years old, epileptic and have not had continuous insurance throughout my college life. I finally got a job that offers insurance and they told me they will not cover my preexisting condition for a year. They also will not cover any physicals. I am dependent on medication and my low income clinic can no longer accept me. Any advice on how to get a prescription? A doctor can’t just write a prescription without know my medical info can they? Can I simply go to a doctor without being sick?”

NC Tar Heel

Dear NC Tar Heel,

One of two things has happened here:

1)      Someone has given you wrong information about your new plan’s covering your pre-existing condition.  OR

2)      Your new plan has (miraculously) not made any changes since 2010 and its annual renewal is late in 2014.

If the truth is item number two, then your plan is one of the very few “grandfathered” plans and it has escaped many health-reform requirements.  That is why they can skip covering routine physicals too.  Its escape plan will end, however, at its next renewal.

For all group plans – even those that are self-insured – the law requires them to cover all pre-existing conditions and certain preventive care services as of their first renewal in 2014.  If your plan has its annual renewal in December, for example, then you would be waiting the whole 12 months for them to cover your epilepsy.

First, I would suggest asking the plan (not the HR department) about this.  Make friends with the member services people, because you may need their help to solve your medication problem.

Ask your current clinid, your friends and family to recommend someone, or consult North Carolina’s NeedyMeds website to find a clinic.  The directory has free and sliding scale clinics and most also accept insurance.  Your plan probably also has a directory of its providers online.

Yes, you can see a doctor without being sick; it would not be a routine physical.  It would be a medication management visit.  Make sure you are clear with the office staff what you need so that you don’t end up getting charged for the visit.

Before your visit to your new doctor, go to the website for your medication’s manufacturer.  The NeedyMeds website also has links to assistance programs by drug makers.  These programs vary widely.  Some require that you have no insurance; others require that your insurance not cover your medication.  (This is where your friends in member services can help you: you may need a letter stating that the plan will not cover your drugs.)

Find out if you qualify for your drug’s program.  It will help to know this before you see your doctor, in case you need to talk about alternative medicines.  The doctor or the office staff may also have some ideas for you.

Your new job might also offer you a flexible spending account, which lets you set aside tax-free dollars to pay for medical costs.  If you do end up having to pay all or part of the cost of your medicines, you could at least pay it in tax-free dollars.

Congratulations on getting a new job with benefits!

Recommend this article
Linda Riddell

About Linda Riddell

A published author and health policy analyst with 25 years’ experience, Linda Riddell's goal is to alleviate the widespread ailment of not knowing what your health plan can do for you.