What seems like one of the most baffling of pre-existing conditions, acne can actually get an applicant turned down for health insurance. While there is barely any need to explain what acne is or how one gets it, it is truly amazing that a person can be discriminated against for any condition, especially one that is hardly life-threatening. Perhaps in early years it can be self-esteem-threatening, but that is not the concern of an established health insurer. Due to the frequency of treatment and the cost of oral and topical prescriptions, severe acne is a pus-filled red flag for insurance companies.
According to the NIAMS, 80 percent of those who have acne are between the ages of 11 and 30, which leads to the good news: if you are under age 19, a health insurance company cannot turn you down for coverage. However, they may increase your monthly premiums depending on the medication you take. While this fuss over broken out skin seems frivolous compared to a major illness, using the topical prescription Retin-A, or the pill Accutane is off limits with certain insurers.
Acne in a severe form may cause an individual to seek surgical care to get rid of marks or scars, which a health insurance company will not cover. However, treatment of acute acne, such as extractions by a dermatologist may be covered in certain cases. Each plan is different and it is necessary to check a plan’s schedule of benefits before proceeding with any type of care you are unsure about. Also, receiving treatments such as microdermabrasion or laser therapy before applying for health insurance will sky rocket your rates, so try to avoid serious dermatological procedures, if possible.
Acne & Health Insurance Underwriting
As mentioned, acne can pose some serious risks to your eligibility for health insurance. More than enough people with acne can attest to being declined and earning the pre-existing condition award. This is all very specific as to which insurance company you choose, the medications you use, and the treatments you seek. A dermatologist is a specialist, obviously, and making regular appointments to receive costly services is not characteristic of an insurer’s ideal policyholder. Insurance companies are looking for low-cost applicants, and the more you push your acne treatment to the limit, the greater your likelihood of rejection.
However, if you have learned to live with medication alone, some insurers will let you in the door. Looking at the underwriting guidelines for an insurer in Florida, we can see a full spectrum of possible outcomes. Those who take medication only may not receive any rate increase at all, if well-managed, or it could climb up to 70 percent more than a normal premium. If a healthy person’s premium is $150 per month, the worst case scenario for a medication-controlled case of acne could be $255 per month for an applicant between age 30 and 39. Bear in mind, the criteria is specific to this health plan’s guidelines.
According to a forum post from six months ago, another major insurer declined someone who takes no medications and only uses topical Retin-A Micro. The thread starter claimed the agent they spoke with said that company’s underwriting guidelines specifically say to decline Retin-A and Accutane. All underwriting guidelines vary, however, as rates and state laws also do. Not too long from now, they will be regulated by federal law and all health insurers will offer coverage to anyone with acne. (See Health Reform & Acne below.)
Health Plan Alternatives for Acne
Try to avoid stressing out if your acne has created a barrier between you and the health plan you were hoping for. There are other options, though they may not be as diverse or plentiful as the coverage from a private insurer. Actually, if you can get on your employer’s group plan, you may have similar quality and provider options as purchasing one for yourself. Many individuals with acne have learned to grow fond of the Pre-Existing Condition Plan (PCIP) in lieu of being rejected. Also, public plans may be able to cover certain types of care for acne.
PCIP
Those who have not been so lucky with the underwriting process and have no other source of health insurance may be able to apply for PCIP. This health plan requires applicants be uninsured for six months or more prior to enrollment. Though a public program set up by the government, it is not free. You will be charged what you can afford according to the PCIP plan options. People who have acne may be able to receive coverage on their medications and potentially some forms of treatment without any exclusion periods, which is an immense benefit.
PCIP covers specialist visits for a $25 copay when using in-network providers (40 percent coinsurance out of network), which would likely include a dermatologist. Prescriptions are covered for $4 when using generics, or $40 per brand name drug. It is priced similarly to a private health plan, and can be more expensive in some cases, but at least they cannot decline you for having acne or cancel your plan.
Employer-Sponsored Benefits
Working for a large company can mean a full-time employee, and occasionally a part-timer, has the option of joining the group health plan. This is the most used form of health insurance in our country, especially for those who have pre-existing conditions. If you have not yet considered obtaining coverage through the workplace, or having your spouse add you to their health plan, it is worth a try. While each company provides a different plan and benefits that cannot be predicted in advance, it will likely cover what you need.
Always consult the schedule of benefits to find out what services are covered and how to obtain them. Costs and providers are also important to keep in mind. The best part of a group plan is that the insurer cannot decline anyone for their health status. Perhaps you employer gets a little upset that their rates increase, but for a person with acne, this may not be as much of an issue as someone with diabetes.
Medicaid & CHIP
Medicaid programs are unique to each state, as far as income guidelines and benefits are concerned. For the most part, if you qualify, you will be able to receive most types of care, and they will make room for special health needs. Depending on the severity of you or your child’s acne, some services may be considered medically necessary, and thus would be covered. If a service is not covered and not seen as medically necessary, you will be stuck paying the full cost. Medicaid does cover prescriptions, though an acne medication may not be approved.
In order to find out what your state’s Medicaid program covers, call your local Department of Human Services (or equivalent health or social services division). They should be able to answer your questions and let you know what services are available. According to various contributors on Acne.org, finding a discount pharmacy arrangement is the best way to go. Apparently, Sam’s Club, Walmart, and Target are the least expensive sources of acne prescriptions.
Health Reform & Acne
The greatest benefit of the Affordable Care Act for people with acne is that they will no longer be limited by their skin to receive health insurance. When this law goes into its final stages in January 2014, anyone who would have previously been denied coverage will be able to apply to whichever health insurance company they choose. Insurers will have to accept you regardless of your condition’s severity or cost, and will not be able to issue an exclusion period to make you pay for treatment out-of-pocket. Elimination riders will also be history.
If health insurance was too expensive for you, the government will also hand out a few million subsidies to individuals who are in-between incomes. Those who are ineligible for Medicaid and will be able to purchase the most minimal plan through their state’s health exchange, another ACA development. While it is yet to be told whether plans will be required to help pay for acne prescriptions and dermatological treatment, it is likely that some will be included, if viewed as a necessity.
Resources
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