What seems like one of the most baffling of pre-existing conditions, acne could 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 interesting that a person could be discriminated against for any condition prior to the Affordable Care Act, especially one that is hardly life-threatening. Perhaps in early years it can be self-esteem-threatening, but health insurers are more concerned with the expense of creams and dermatologist visits. Due to the frequency of treatment and the cost of oral and topical prescriptions, severe acne has been a pus-filled red flag for insurance companies until the laws changed.
According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), 80 percent of those who have acne are between the ages of 11 and 30, meaning your premiums will at least be lower due to your age. In the past, they could increase your monthly premiums depending on the medication you take. Now, if you use the topical prescription Retin-A, or the pill Accutane to control your acne, insurers cannot adjust your rates but not every health plan will cover your treatment. Despite the changes in insurance laws, it is still necessary to ask an insurer if any of their policies have a dermatology benefit or if their formulary includes acne medication.
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. If you have used treatments such as microdermabrasion or laser therapy before applying for health insurance, you will still be accepted for coverage — though you wouldn’t have been before health reform.
Acne and Health Insurance Underwriting: Past and Present
Health Reform and Acne
The greatest benefit of the Affordable Care Act for people with acne is that they are no longer limited by their condition to receive coverage for a fair rate. Beginning January 2014, anyone who was denied coverage is able to apply to whichever health insurance company they choose. Insurers 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 covered treatment out-of-pocket. Elimination riders are also illegal, so no insurer can exclude a certain benefit that should be covered for the duration of your policy.
If health insurance on the private market is out of your price range, 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 a Silver (mid-level) plan through their state’s health insurance exchange. As health plans vary and so will the benefit schedules under the exchanges, you should always ask whether acne prescriptions and dermatological treatment will be a covered benefit when applying.
Many people with acne can attest to being declined and earning pre-existing condition status before the ACA. Rejection was specific as to which insurance company you chose, as well as medications and treatments. Seeing a dermatologist regularly would have a higher likelihood of decline than just taking medication. Looking at the 2012 underwriting guidelines below for an insurer in Florida, we can see a variety of possible outcomes. Those who took medication only might not receive any rate increase at all if well-managed, or rates could climb by 70 percent. If a healthy person in their 30s was charged $150 per month in 2012, the worst case scenario for a medication-controlled case of acne would have been $255 per month, according to this insurer’s guidelines.
According to a forum post from April 2012, 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.
Other Health Plans for Acne
If you are eligible for coverage through your employer or the government-funded Medicaid program, you will not qualify for a plan through the exchange, but you always have the choice of applying for an individual policy, unless you can’t afford it. Group insurance policies are also required by health reform to include a wide range of benefits, so you may have coverage for some acne treatments. Medicaid benefits vary from one state to another, and usually do not cover acne, as it might not be considered medically necessary to treat. As this is such a widespread condition in our country, Medicaid beneficiaries have found ways to reduce their blemishes on a budget, even when insurance doesn’t pay.
Working for a large company means a full-time employee has the option of joining the group health plan. This is the most used form of health insurance in our country, and Obamacare requires all employers to offer essential health benefits to their full-time workers. If you have not yet considered obtaining coverage through the workplace, or having your spouse add you to their health plan it is worth comparing the cost to individual plans. While each company provides a different plan and benefits that cannot be predicted in advance, group coverage is often very comprehensive.
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. ACA regulations ensure that at least ten categories of care are included, but specifics are up to the insurer and your employer.
Medicaid and CHIP
Medicaid programs are unique to each state as far as income guidelines and benefits are concerned. If you qualify, you will be able to receive many types of care, but special health needs are covered only based on medical necessity. Depending on the severity of your or your child’s acne, some services may be considered medically necessary, and thus would be covered. If a service is not covered, you are responsible for paying the full cost. Medicaid does cover prescriptions, but an acne medication may not be approved.
In order to find out what your state’s Medicaid program covers, call your local Department of Health (or equivalent health or social services division). They should be able to answer your questions and let you know what services are included. According to various contributors on Acne.org, finding a discount pharmacy arrangement is the best way to go. Seeking out discounts via Sam’s Club, Walmart, Costco and Target are the least expensive sources of acne prescriptions.
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