How Do We Define Pre-Existing Conditions?

September 6th, 2017

In the Health & Wellness Department, we are asked, “What is considered a pre-existing condition?” several times a day by both members and providers. The review and management of pre-existing conditions make up a large part of our work, so one of my goals is ensuring that our members have a good understanding of how we address these particular circumstances.

One of the easiest ways to explain this topic is to give examples of pre-existing conditions for better understanding:

Our Sharing Guidelines define pre-existing conditions in this way: “Chronic or recurrent conditions that have evidenced signs/symptoms and/or received treatment and/or medication within the past 36 months are not eligible for sharing during the first year of membership.” (Full explanation can be found in section IV. C. 15. of the Sharing Guidelines)

Let’s focus on a couple key words within that definition:

Chronic: a condition persisting for a long time. For example:

  • A member is a migraine sufferer but has not had a migraine for over a year prior to enrollment. That member then begins to experience migraines for several months in a row and seeks medical attention. Any treatment or care related to the migraines would be considered pre-existing.
  • We often receive clinical notes for review in order to determine whether a medical condition is eligible for sharing. Within those clinical notes, the physician may classify a medical condition as “chronic acute”. This means that the patient has had a medical condition for an extended period of time and is now experiencing a flare-up of that same condition. If a flare-up occurred within the 36 months prior to enrollment, this would be considered a pre-existing condition.
  • A member’s child had speech therapy prescribed by a pediatrician and/or physician two years prior to enrollment. After enrollment, the parents change providers and the new pediatrician and/or physician recommends further speech therapy for the child. This would be considered a pre-existing condition.

Recurrent: a condition occurring often or repeatedly. For example:

  • A member had back pain during the 36 months prior to enrollment. Once enrolled, this member visits his/her physician and the physician diagnoses the condition that has been causing the back pain. Any care or treatment for this condition would be considered pre-existing.
  • A member was diagnosed with a thyroid disorder 20 years prior to enrollment and has taken maintenance medication for the condition within the 36 months prior to enrollment. Any treatment or care related to this condition is considered a pre-existing condition.
  • A member received allergy testing in the 36 months prior to enrollment. After enrolling, his or her allergist recommends allergy injections. This care would be considered pre-existing.

I’m hopeful that these examples have helped you understand how pre-existing conditions are classified under our Sharing Guidelines. Here are a few things to keep in mind as you prepare to see your doctor at any time, for both pre-existing and new conditions:

  • Read the updated Liberty HealthShare Sharing Guidelines in their entirety. If you don’t understand what is written, call customer service at 855-585-4237. They would welcome the opportunity to answer any questions or concerns you may have.
  • Before your appointment, make a list of your concerns and symptoms.
  • Explain how you feel in detail. Only you can give your doctor that information.
  • Be accurate. When did the symptoms start? Are they constant or do they come and go? Is there anything that relieves the symptoms?
  • Have a conversation with your doctor about the risks, the success rate, the side effects, the cost, etc. of treatment.
  • Repeat back your understanding of what your physician has said. Sometimes physicians speak in medical jargon that makes it difficult to clearly understand what they say.
  • If your physician recommends surgery, imaging studies, hospital admission, a cardiac catheterization, a PET scan, endoscopy, cancer treatment, outpatient surgery, obstetric and prenatal care, cardiac rehabilitation, acupuncture, physical, occupational, speech, or respiratory therapy, or other conditions (detailed in section IV. C. 19. of our Sharing Guidelines), please remember to call our pre-notification number (888-604-4337) for eligibility.
  • You can also access the Member Steward Advisory Program through the pre-notification phone line. They will be happy to assist you in locating a provider who will meet your needs while also prioritizing cost. This service can be utilized for both pre-existing and new conditions.

Remember, educating yourself about your own health and the Liberty HealthShare guidelines is your best defense as you navigate a confusing healthcare system. Arm yourself with information and be an advocate for yourself. You are in charge of your health and what you will pay for healthcare. Ask questions, do research and price comparisons, and access the tools Liberty makes available to you. We are here to answer your questions and assist you as you make wise healthcare stewardship decisions.

Always My Best,

Sue Rohr

Health & Wellness Director, Liberty HealthShare