Insurance coverage/pre-existing condition

MummyGruetzie · July 2010

Sorry. I have another hard question again.

When we finalize our adoption with DD in a month, she's eligible for Medicaid as a secondary insurance if we switch her to ours as a primary or we can keep it as a primary.

We have 2 HUGE surgeries that are coming up. One will cost $50,000+ with surgery and total rehabiliation afterwards. I have no idea what the other will cost.... its a very intense, very uncommon brain surgery that isn't listed in any of our insurance stuff. Probably not cheap either.

So my question... SW has been saying that we should drop the medicaid totally and just go with our insurance, which seemed odd to me, but then the other day kinda slipped that all of her conditions will be considered "pre-existing" until the new health care reform stuff starts in a year or so.

So my question. . . When you adopted your DC, were their conditions considered pre-existing? Any advice on how you were able to afford services/surgeries if so?

I feel so frustrated by all of this insurance/finance stuff. I just want to help DD and don't want to not get her a surgery she needs just because we can't afford it. I'm feeling like we need to rush and have the surgery done so that we can make sure, but wanted to wait until we'd had a final opinion since the first two disagreed.

Please shed some light. . .

mommyof4boys · August 2010

Lurker, but regular on the SN board. I'd keep the Medicaid as she is eligable as a child with a SN. We are currently waiting to re-apply for Christopher as we can get SSI and a medical card for him.

MummyGruetzie · August 2010

mommyof4boys:
Lurker, but regular on the SN board. I'd keep the Medicaid as she is eligable as a child with a SN. We are currently waiting to re-apply for Christopher as we can get SSI and a medical card for him.

Hi Mommy!

Thanks for hopping over to answer my question. I'm pretty sure we'll just do the Medicaid so that we don't end up not being able to afford the surgeries (we have good insurance for people who don't get sick, but if you have any issues at all... it sucks... huge deductibles).

I am very curious about the pre-existing thing, though. That seems crazy that every kid who is adopted would fall into the category of not being covered by insurance?!?!

GulfCoaster · August 2010

MummyGruetzie:

I am very curious about the pre-existing thing, though. That seems crazy that every kid who is adopted would fall into the category of not being covered by insurance?!?!

The Dept. of Labor has some basic info on employer-sponsored group insurance plans:

https://www.dol.gov/ebsa/publications/newborns.html

Go_Dawgs · August 2010

If this is a group policy with your employer, you shouldn't have to worry about pre-existing conditions so long as you enroll her during the time required by the insurance company. However, there is still no way I would get rid of Medicaid. That is one of the huge benefit your type of adoption and I personally would keep Medicaid as primary and your group policy as secondary, if that is allowed. Otherwise, I would do research on coverage and possibly just use Medicaid, or at the very least keep it as secondary.

GBCK · August 2010

Go_Dawgs:
If this is a group policy with your employer, you shouldn't have to worry about pre-existing conditions so long as you enroll her during the time required by the insurance company. However, there is still no way I would get rid of Medicaid. T

This is what I was thinking...pre-existing usually won't kick in if this is a group plan--so I suppose that begs the question, is it a group plan or do you buy your own, individual insurance?

jehnm · August 2010

I'm a medical social worker and I would NEVER tell anyone to drop Medicaid. Truthfully, it's usually the best insurance in some ways because you don't pay a single copay in most states. However, in our state, there are some hospitals that won't accept you for certain treatments/surgeries if Medicaid is your only coverage.

I doubt Medicaid will allow you to keep it as primary, but if they do, go for it. If you have commercial insurance as primary, then the reimbursement rate that the commercial will pay for service will likely be so much more than Medicaid that Medicaid will never have to pay anything. With my state, if you have Medicaid, then the provider has to write off anything that Medicaid refuses to pay. However, with that being said, having Medicaid often qualifies a patient for certain discount programs and makes meds cheap so definitely keep it.

I could go on and on, but it's so state specific and so in depth. My recommendation is to talk with a social worker at your nearest children's hospital. They should be well versed on your state!

MummyGruetzie · August 2010

GulfCoaster:
MummyGruetzie:

I am very curious about the pre-existing thing, though. That seems crazy that every kid who is adopted would fall into the category of not being covered by insurance?!?!
The Dept. of Labor has some basic info on employer-sponsored group insurance plans:
https://www.dol.gov/ebsa/publications/newborns.html

Oooh! This is good. Thanks!

MummyGruetzie · August 2010

GBCK:
Go_Dawgs:
If this is a group policy with your employer, you shouldn't have to worry about pre-existing conditions so long as you enroll her during the time required by the insurance company. However, there is still no way I would get rid of Medicaid. T
This is what I was thinking...pre-existing usually won't kick in if this is a group plan--so I suppose that begs the question, is it a group plan or do you buy your own, individual insurance?

Its a group plan that DHs work just switched to this year and I hate it! There's so much work to figure out all of the deductibles and what not and it has a max coverage at some point, which leaves me freaked out that after a few surgeries for our new DD we won't have any coverage for the rest of our family.

From what I understand our options are:

1) use our insurance only

2) use Medicaid only

3) use our insurance and have Medicaid as secondary

MummyGruetzie · August 2010

jehnm:
I doubt Medicaid will allow you to keep it as primary, but if they do, go for it. If you have commercial insurance as primary, then the reimbursement rate that the commercial will pay for service will likely be so much more than Medicaid that Medicaid will never have to pay anything. With my state, if you have Medicaid, then the provider has to write off anything that Medicaid refuses to pay. However, with that being said, having Medicaid often qualifies a patient for certain discount programs and makes meds cheap so definitely keep it.
I could go on and on, but it's so state specific and so in depth. My recommendation is to talk with a social worker at your nearest children's hospital. They should be well versed on your state!

We have a group insurance plan from DHs work. Insurance confuses the heck out of me. Do you mind explaining the line about the reimbursement rates and the provider writing it off? ... I've been trying to understand what it means to have it as a secondary insurance. Will we still pay our copay and deductable for our first insurance and then submit it to Medicaid for reimbursement of those or will having the secondary insurance not really mean anything at all?

Thanks so much for your help with this. I'm trying to look it all up, but like I said insurance stuff is so confusing to me and I just wind up getting even more confused.

GLynn2009 · August 2010

If Medicaid will pay for the treaments your DD needs I would just do that if not I would out her on your insurance and have Medicaid as the secondary.

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