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Benefits/Waiting Period Question from someone in Benefits/HR
Jan 31, 2012

I recently became benefits-eligible in CA at my job. The problem is, I work in HR and Benefits, though in areas that do not involve benefits enrollment, so I do not understand the waiting period clause in my benefits package.

I do not want to discuss my HIV+ status to any co-workers, but I work with the entire benefits department. I also work closely with all of HR, and I just do not have a level of trust with anyone who would be able to answer these questions.

I overheard the benefits analyst and assistant say there's a one-month waiting period for pre-existing conditions for the plan that I would like to enroll in. However, when reading my enrollment package, it talks about a 12 - 18 month exclusion period if I've received any treatment in the past 6 months, and proof of creditable coverage. I do not have any prior plan coverage, except going to my community clinic and being enrolled in ADAP. I don't understand where this puts me - does this mean I wait 1 month for coverage in general, then up to 18 more months for HIV-related coverage? What happens if this is true and I make slightly more than the ADAP income limit in CA? Would I be ineligible for all care and medication?

Is there CA law or plan-specific information (it's UHC EPO) I can read without speaking with my co-workers?

There is one other plan option that does not have an exclusion period, so if what I assume is true, I would be forced to take it, though I would not prefer it.

Thank you in advance.

Response from Mr. Chambers

New employer; new insurance. That's understandably very scary.

Pre-Existing conditions limitation provisions would apply to you since you don't have any prior coverage (treatment at a clinic and ADAP are not considered to be "creditable coverage").

The phrase you read probably means that if you enroll when first offered, your waiting period for HIV related charges is 12 months The 18 months likely only applies to persons who wait and enroll later during an open enrollment period.

I'm sorry I have to say "probably" to that, but not being able to read the exact provision in your plan document/booklet, I'm just giving you an educated estimate.

Look in your health insurance booklet for a "Pre-Existing Conditions Limitations" provision. It is sometimes a separate heading; other times it's part of Exclusions and Limitations. It should either confirm what I said or give a different waiting period.

It also sounds like your employer is large enough to give you a choice of plans. HMOs do not have a Pre-Existing Conditions Limitation so you may want to enroll in that now and change to the PPO at the next open enrollment after you've gone through the pre-existing period. The problem there is you will have to change doctors, but you may want to move to a private physician anyway.

Every medical group that contracts with an HMO is required to have an HIV specialist. If you join the HMO and like the doctor, then you may want to stay with it as HMOs are usually cheaper and require less out-of-pocket payments. If not, you can still change plans at open enrollment.

Be sure to continue your ADAP as it will pay (depending on what state you live in) what the insurance doesn't pay for medications.

Good luck with the new job, Jacques

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