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Clarification of Insurance Coverage
Apr 23, 2007

I am a public school teacher and have insurance through the school district which I enrolled in during open enrollment. My distric offers several different HMO/PPO plans through different companies. Can I change insurance companies during our open enrollment period with a pre-existing condition (HIV)? Further, I may decide at some point to relocate to another large city which would have similar insurance benefits (i.e. several large providers [HMO/PPO]) with open enrollment? Could I make such a move with this pre-existing condition? I like my infectious disease doctor and I don't plan to make any moves at present, but in the years to come, it may an option, and I'm wondering if it's realistic to think that I could change insurance providers in this case.

Response from Ms. Franzoi

Typically, at open enrollment, if an individual switches from one health plan to another, there is no new pre-existing condition limitation applied as you have been continuously covered by another plan sponsored by this employer. However, check the language in the plan summaries carefully with respect to this. Furthermore, if you have had continuous coverage for at least 12 months, even if there is a pre-existing condition clause, it cannot be greater than 12 months and the plan would have to recognize your prior period of coverage towards this period (HIPAA regulations). This is what would happen if you were to relocate and get coverage from a new employer. As long as you don't have a break in coverage of 63 days or more, the new plan would have to recognize your prior period of coverage towards any pre-existing limitation period and this period cannot be greater than 12 months.

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