HIPAA and Maternity: A Dialectic (or a Debacle)…

My good friend, insurance guru Bob Vineyard and I have been engaged in a lengthy, interesting, and frustrating email correspondence.

It all started innocently enough: Bob wrote to tell me that he got his hand slapped (which is in itself not really all that surprising) because – apparently – HIPAA doesn’t consider pregnancy a pre-existing condition.

Usually.

And that’s where it gets interesting.

According to the DOL (Department of Labor):

“If you find a new job that offers health coverage, or if you are eligible for coverage under a family member's employment-based plan, HIPAA includes protections for coverage under group health plans that:Limit exclusions for preexisting conditionsMoreover, under HIPAA, preexisting condition exclusions cannot be applied to pregnancy, regardless of whether the woman had previous health coverage."

This seems counter-intuitive, given that other provisions in HIPAA limit coverage for pre-existing conditions. So, I identified 4 scenario’s where this might apply, to see where this new information would lead us:

1) Jane was covered under a group plan at Employer A, got a new job at Company B, and immediately enrolled in their group health plan.

In this case, there’s no problem; everyone agrees that HIPAA provides for continuity of coverage, and so Jane’s pregnancy would be covered.

Sort of: if there’s a waiting period for new hires, she’s got a problem. But that’s another post.

2) Jane was covered under an individual plan, and then went to work at XYZ Widgets.

Again, as in #1, there should be no problem, because HIPAA recognizes individual coverage as creditable toward group. In other words, the pregnancy should be covered (subject, of course, to the same waiting period proviso as in #1)

3) Jane had no insurance, and went to work at XYZ Widgets. Apparently, HIPAA says that the pregnancy must be covered.

Does it? According to an article on Parenting.com, “if (Jane) had no insurance, got pregnant, then landed a new job with insurance, (her) new health plan would not have to immediately cover (her) pregnancy.” Now, I’m not crazy about relying on the net for such critical information, but it does seem to make some sense. OTOH, I’ll keep digging, and update/correct this answer as I learn more.

4) Jane works at XYZ Widgets, but has no insurance because she waived (declined) coverage when she was originally eligible. Now, she is considered a “late enrollee,” subject to an 18 month waiting period for pre-existing conditions.

Not so fast there, pardner. According to another site, The Employers Council, “(n)o preexisting condition limitations may be imposed on pregnant women…” But, also according to that site, Jane would have had to have had [ed - that sounds clumsy] other coverage in place when she originally waived. Otherwise, she is indeed a late enrollee.

If this sounds convoluted and confusing, it is. I’m still not sure how scenarios 3 and 4 will ultimately “shake out,” so I’m going to consider this post: Under Construction.