Health FAQs

A preexisting condition is often defined as a medical condition (i.e., an injury or illness) for which treatment was received or recommended during the 6 months prior to the insured’s effective date of coverage under a health plan.

A preexisting conditions clause excludes coverage for preexisting conditions for possibly as long as 12 months after the effective date of coverage, but can be shorter. Pregnancy is not a pre-existing condition.

Although providing very broad coverage, most plans typically contain a number of exclusions. Common exclusions include medical expenditures arising from:

  • Cosmetic surgery unless required to correct a condition resulting from an injury or a birth defect
  • Occupational injuries and illnesses that are otherwise covered under a Workers’ Compensation law
  • Routine dental and vision care (care required for treatment of an injury and dental and eye surgery are frequently covered, however)

Other common exclusions relate to benefits provided by government agencies (e.g., VA hospitals) and expenses paid under other insurance programs, including Medicare and Personal Injury Protection Coverage under your Personal Automobile Policy.

Most plans available today do not require a referral to see a specialist, but you will still need to get pre-authorizations for some procedures.

Most of the plans we see today are either an EPO ( Exclusive Provider Organization) or HDHP (High Deductible Health Plan). There are others, but these are the most common.

EPOs have copays for office visits, most tests and prescriptions. Hospital stays, surgery and invasive tests are generally covered after a deductible or cost-sharing is applied.

HDHPs are usually coupled with a Health Savings Account (HSA) and have a deductible of at least $1,150 before the insurance portion kicks in. The deductible can be as high as $5,950 for an individual and $11,900 for a family. These deductibles are indexed annually.