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Individual & Family Health Insurance
Medicare Supplements
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When do individual health insurers have to sell me a policy?

In California, your ability to buy individual health insurance policy may depend on your health status. There are certain circumstances, however, when you must be allowed to buy individual health insurance.

  • · Unless you are HIPAA eligible, insurers that sell individual health insurance in California are free to turn you down because of your health status and other factors. When applying for an individual policy, you may be asked questions about health conditions you have now or had in the past. Depending on your health status, insurers might refuse to sell you coverage or offer to sell you a policy that has special limitations on what it covers.

However, under no circumstance can you be turned down, charged more or face a pre-existing exclusion period because of your genetic information. Genetic information includes the results of a genetic test and your family history of health conditions

  • · If you have trouble buying private health insurance due to your health status, you may be eligible for the Major Risk Medical Insurance Program (MRMIP).
  • · Persons who are HIPAA eligible are guaranteed the right to buy an individual policy from private insurers. However, insurers can limit your choices to two policies – either their two most popular policies or two representative policies. The two representative policies must include a high option policy and a low option policy.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy individual health policy in every state and are exempted from pre-existing condition exclusion periods. In California, you are guaranteed the right to buy coverage from any insurer selling individual policies.

To be HIPAA eligible, you must meet all of the following:

  • · You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.
  • · You also must have used up any COBRA or state continuation coverage for which you were eligible.
  • · You must not be eligible for Medicare, Medicaid or a group health plan.
  • · You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be HIPAA eligible.)
  • · You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.

HIPAA eligibility ends when you enroll in an individual policy, because the last day of your continuous health coverage must have been in a group plan. You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.

  • · Under California law, newborns, adopted children, and children placed for adoption are automatically covered under the parents’ individual health policy, if the plan provides coverage for dependents, for a certain number of days, as specified by the individual health insurance policy. The policy may require that the parent enroll the child within a certain number of days in order to continue coverage.
  • · If you have a disabled child, that child may remain covered under your individual health insurance policy after he or she reaches the age at which dependent coverage is usually terminated. To qualify, your adult son or daughter must be incapable of self-sustaining employment because of a physically or mentally disabling condition and must be chiefly dependent on you for support. Proof of incapacity must be furnished within 60 days of notification by the insurer that your child is no longer eligible due to attainment of the limiting age specified in the policy.
  • · It depends on what you buy. In general, California does not require health plans in the individual market to sell standardized policies. Health insurers can design different policies and you will have to read and compare them carefully. California does require all individual health policies to cover certain benefits – for example, some cancer screenings. Check with the California Department of Insurance or the Department of Managed Health Care for more information about mandated benefits.
  • · If you are HIPAA eligible, no pre-existing condition exclusion period can be imposed on your coverage.
  • · If you are not HIPAA eligible, the rules for pre-existing conditions for individual health insurance policies are somewhat different from those under group health plans. In general, you may face a 6-month pre-existing exclusion period if the policy covers three or more people and 12 months if the policy covers one or two people. You can get credit for any prior continuous creditable coverage you had provided you became eligible for the new individual health insurance police within 62 days of termination of your prior coverage.

What will my individual health insurance policy cover?

What about coverage for my pre-existing condition?

Individual health insurers can count as pre-existing conditions only those for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice in the 6-month period (if the policy covers 3 or more people) or 12-month period (if the policy covers 1 or 2 people) prior to obtaining the individual health policy.

  • · Pregnancy may be considered a pre-existing condition in an individual health insurance policy. However, genetic information cannot be used as a basis for a pre-existing condition
  • · If you are HIPAA eligible, California law limits the premium you can be charged. Even so, you may find that your premiums are quite expensive.
  • · If you are not HIPAA eligible, California does not limit what you can be charged. Individual premiums can vary due to health status, age, gender, family size, and other factors. However premiums cannot vary based on your genetic information.

What can I be charged for my individual health insurance policy?

When you renew your individual health insurance policy, your premiums can increase as you age or your health declines.

Can my individual health insurance policy be canceled?

  • · Your health coverage cannot be canceled because you get sick. This is called guaranteed renewability. You have this protection provided that you pay the premiums, do not defraud the company, and, in the case of HMO plans, continue to live in the plan service area.

However if you make a claim during the first two years of coverage under your policy, the insurer might re-investigate information you provided during the application process to determine whether you made a misstatement.  If so, the insurer might try to take back your policy and void coverage altogether.

If you become involved in one of these “post-claims” investigations, be sure to call the California Department of Insurance or, if your insurer is an HMO, the California Department of Managed Health Care to learn more about your rights.

  • · Your health coverage may also be canceled if the insurer or HMO discontinues your health plan or withdraws from the individual market. However, if you are covered under a health plan that has been discontinued by a company that still sells other health insurance in individual market, your insurance company must offer you one of those other individual policies.

· Some insurance companies sell temporary health insurance policies. Temporary policies are not guaranteed renewable. They will only cover you for a limited time, such as 12 months or less. If you want to renew coverage under a temporary policy after it expires, you will have to reapply and there is no guarantee that coverage will be reissued at all or at the same price.