Metal Mouth Message Board

Hi, long time lurker who finally got braces a month ago and wanted to get people's take on this. Two weeks after I got my braces on I was headhunted and offered a position with better pay, a better bonus, and more interesting responsibilities than at my current one. The thing that's stopping me is my insurance.

I will need double jaw surgery 6-7 months from now, and I'm getting it because my current employer has great health insurance and I was pre-approved for every piece of two complicated operations. All I will pay is $250 for an overnight stay at a hospital.

I had braces/retainers/appliances as a kid, and although my teeth ended up straight, my upper jaw was narrow, and my teeth wore unevenly. Ever since I was 18 my dentists have told me to get jaw surgery, but it costs about $40k here in the Northeast. I am in braces again and was happy as a clam until I got this job offer.

The new company uses BCBS rather than Aetna, my current insurer, and my surgeon and orthodontist would need to submit all the paperwork again. Thanks to the Affordable Care Act, BCBS cannot choose to issue a blanket denial due to it being a pre-existing condition, but there is also no guarantee that BCBS would cover the surgery. If they don't, I can't afford it on my own. I suppose I could take out a loan, but I don't want to.

Any advice?

You'll need to check the actual text of your new employer's plan to verify it covers Orthognathic surgery; not all plans do. (And it varies by employer, not insurance company... the insurance will cover whatever your employer tells it to cover.)

If your new plan does cover orthognathic surgery (or does not exclude it, anyway) then I think you'll be fine. I would think your approval letter from Aetna might even help a little.

Checked the text and they don't exclude orthognathic surgery. However, I'm not eligible to get coverage until 12 months after my start for anything looked at by the previous (current) insurance in the past six months.

So they might approve it, but I would have to wait a year to see. Grumble.

A couple other things to think about; your available sick time (and what your new bosses might say) and when your healthcare would officially start.


ETA looks like you figured out what I typed...

uncleezno wrote:Checked the text and they don't exclude orthognathic surgery. However, I'm not eligible to get coverage until 12 months after my start for anything looked at by the previous (current) insurance in the past six months.

So they might approve it, but I would have to wait a year to see. Grumble.

Hmmm... usually if you maintain continuous coverage the pre-ex exclusion is waived, but I'll readily admit to not being an insurance expert.

Yeah, insurance is a pain to figure out, even with the ACA. What it says is that an insurer can't refuse to put me on their plan because of a pre-existing condition. It doesn't say that they can't refuse coverage for a specific problem. I also realized my current position would give me short-term disability for two weeks after the surgery, which means I wouldn't burn any PTO, whereas at the new job I would have to use PTO. Pain in the butt.

The bit about the pre-ex exclusions not applying if you have continuous coverage is a HIPAA provision (the "P" in HIPAA stands for Portability), not the ACA. Read up here: http://www.dol.gov/ebsa/pdf/caghipaa.pdf .

SirWired, thank you for the link - I didn't realize it was a stipulation of HIPAA. I read the document, and within the first few pages it clearly states that there's a six-month 'look back' period where exclusions are discovered and a 12-month 'look forward' period where they don't have to cover the condition.

I guess that's better than how it used to be? Still less than ideal for me. I am going to try and push my surgeon and the hospital for a real estimate of the surgeries.

You need to be reading the provisions on "creditable coverage"... basically, the pre-ex period is reduced by the number of days during the period you had "creditable coverage" which includes virtually all employer-provided plans.

I saw that section as well, but it seems too good to be true. If I am understanding it correctly, anyone on an employer's group healthcare plan for more than a year who then takes a new job without any gap in insurance cannot be denied coverage for any condition discovered at any time as the new maximum exclusion period is only 12 months. So, since I have been with my employer and on their health plan for over a year, the 12 month exclusionary period with the be plan should drop down to zero. Is that correct?

Thank you so much for helping me out with this stuff! It's ridiculous that the insurance coordinator at my surgeon's office and the plan administrator at the new job are less familiar with this stuff than you!

You could try to negotiate it as a package with your new employer. Some skills are in such demand that these things can be negotiated.

While I was headhunted and offered a better package them what I am currently making, I sadly do not think I could convince them to pony up for surgery if it gets denied by BCBS.

Couldn't hurt to ask, I suppose!

My opinion, for whatever it's worth, is that you should stick with your current job. You run a huge financial risk if BCBS doesn't approve the surgery. These surgeries often cost $60,000 and up. If you ended up having to take out a loan to pay that, your higher pay at the new job could just end up going toward medical expenses. And that deductible you've got? If you see that in another plan, I'll be in shock. I haven't seen a deductible less than $3000 in 10 years. Then figure in co-insurance, and you're looking at at least $5000, if not more, before insurance covers it fully. Just my two cents.

uncleezno wrote:I saw that section as well, but it seems too good to be true. If I am understanding it correctly, anyone on an employer's group healthcare plan for more than a year who then takes a new job without any gap in insurance cannot be denied coverage for any condition discovered at any time as the new maximum exclusion period is only 12 months. So, since I have been with my employer and on their health plan for over a year, the 12 month exclusionary period with the be plan should drop down to zero. Is that correct?

Thank you so much for helping me out with this stuff! It's ridiculous that the insurance coordinator at my surgeon's office and the plan administrator at the new job are less familiar with this stuff than you!

You are reading it correctly; this concept was one of the major provisions of HIPAA. Without it, anyone with a chronic illness (or a family member with one) would be pretty much unable to ever switch employers (voluntarily or otherwise.)

You'll need to collect a "certificate of creditable coverage" from your old insurer or employer (I don't know which), and your doctor's office should probably send it in as part of the pre-auth package for BCBS.

I could maybe understand the doctor's office not knowing about this, but it's pretty sad the HR person at your new company doesn't.

boodles8 wrote:My opinion, for whatever it's worth, is that you should stick with your current job. You run a huge financial risk if BCBS doesn't approve the surgery. These surgeries often cost $60,000 and up. If you ended up having to take out a loan to pay that, your higher pay at the new job could just end up going toward medical expenses. And that deductible you've got? If you see that in another plan, I'll be in shock. I haven't seen a deductible less than $3000 in 10 years. Then figure in co-insurance, and you're looking at at least $5000, if not more, before insurance covers it fully. Just my two cents.

My deductible is well under $3k. And my in-patient co-pay was $450 (no deductible). I'm pretty sure all the various BCBS's have the same coverage criteria, and it's pretty broad when it comes to orthognathic surgery. (At least compared to Cigna, my previous insurer.)

To the OP: If you want to be safe, you can google "(Insurance company name here, such as BCBS NC) orthognathic" and you should be able to see a copy of the coverage criteria. You can compare it to Aetna's. If it's the same or looser, you should be in good shape.