Hello PIB readers! As promised, here is the second installment of the “Top Five Insurance Questions.” This segment deals with group medical coverage, and several concerns associated with a PIB reader’s group medical insurance pollicy.
Here’s the question from Pam of Portland, Oregon: “I have a group insurance policy where I work that covers my daughter and me. The plan is through ——— PPO (carrier omittted purposely), and they are telling me that my daughter’s pregnancy isn’t covered as part of their plan. My daughter lives with me, and is dependent upon me for support. She (the daughter) is 19 years old, and is a full-time student attending a local college. She can’t afford to pay for the pregnancy or for insurance on the child once it’s born, and neither can I. Does my group medical insurance stink? Please help me!”
OK Pam…let me see what I can do to help clear things up. Before I answer your concerns, I have to go a little technical on ya…sorry ’bout that! Specifically, a PPO is not an insurance plan. Technically, a PPO is referred to as a “health care service contract.” What does this mean to you? Not a darn thing…the Oregon statutes and rules apply uniformly to PPOs, HMOs and true major medical insurance when considering coverage for pregnancy and newborn children. Go ahead and call it an insurance plan…everyone else does!
Now on to your question. Without having the particular specifics of your plan, I will assume the following:
- It is a PPO that covers hospital, surgical and medical expenses, and not some limited plan that provides lesser coverage.
- Your daughter has been continuously insured under your group plan as a dependent.
- The policy is in-force and has not been cancelled due to non-payment of premium by your employer.
- That the plan is NOT a PPO-based HSA with some huge deductible that would eliminate coverage due to the expenses incurred during the pregnancy being less than that deductible (doubtful).
That being said…here we go. When considering Oregon statutes (called the Oregon Revised Statutes, or “ORS”) and rules (Oregon Administrative Rules, or “OAR”), here’s the deal regarding the pregnancy itself:
Effective as of 6/1/2006, OAR 836-053-0003 states that “A carrier may not impose an exclusion period or a waiver in a health benefit plan for pregnancy and childbirth expenses, for which coverage is required by ORS 743.693.“ This simply means that pregnancy cannot be considered a pre-existing condition anymore. If your daughter is enrolled in the plan, coverage will apply if she becomes pregnant, which obviously, she is!
When looking at ORS 743.693, we see that this law states “All health benefit plans as defined in ORS 743.730 must provide payment or reimbursement for expenses associated with pregnancy care. as defined by ORS 743.845, and childbirth. Benefits provided under this section shall be extended to all enrollees, enrolled spouses and enrolled dependents.” So, at this point it appears as if coverage must be provided if your plan meets the ORS definition, so now we have to find out if the plan is considered a health benefit plan. Let’s continue…
ORS 743.730 defines a health benefit plan as “any hospital expense, medical expense or hospital or medical expense policy or certificate, health care service contractor or health maintenance organization (HMO) subscriber contract, any plan provided by a multiple employer welfare arrangement or by another benefit arrangement defined in the federal ERISA act of 1974, as amended.” Your plan appears to meet the definition required under the statutes. Next!
ORS 743.845 defines pregnancy care as “the care necessary to support a healthy pregnancy and care related to labor and delivery.” Now we know the definition of “care” under this statute.
My conclusion, if my above assumptions regarding your coverage are correct, is that the group policy must cover the pregnancy and it’s associated costs.
Now, onto the birth of the child and related concerns. It appears as if you are in luck here as well, as ORS 743.707 states that “all individual and group health insurance policies providing hospital, medical or surgical expense benefits that include coverage for a family member of the insured shall also provide that the health insurance benefits applicable for children in the family shall be payable with respect to:
- A newly born child of the insured from the moment of birth; and
- An adopted child effective upon placement for adoption.”
This law also requires that the policy cover the “necessary care and treatment of medically diagnosed congenital defects and birth abnormalities.” It looks as if the child is covered, and that coverage includes care for problems at birth for the mother and the child.
Please make sure that you read the law fully, and note that in order for coverage to continue on the child, the insured must report the birth event to the insurer within 31 days, and if required, pay any additional premium within that period of time. If you do not report the event to the carrier within the prescribed time-frame, the child can be denied coverage.
To be safe…there is a disclaimer attached to this information:
I AM NOT FULLY SURE AS TO WHAT KIND OF POLICY COVERAGE YOU ARE INSURED UNDER. AS A RESULT, THIS INFORMATION MAY NOT BE ACCURATE!
If any of our kind and informed readers would care to comment…feel free!