When do insurers have to sell me an individual insurance policy?

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

• In general, companies that sell individual health insurance in the District of Columbia, other than CareFirst BlueCross BlueShield, are free to turn you down because of your health status and other factors. When applying for individual health insurance, you may be asked questions about health conditions you have now or have 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.
• Currently, CareFirst BlueCross BlueShield (CareFirst) offers one individual health insurance policy to any D.C. resident regardless of health status. This policy is called the Blue Preferred Open Enrollment policy. CareFirst does impose any preexisting exclusion periods on enrollees of this policy, so you will not have to wait to receive treatment of your preexisting conditions.  Premiums for this policy will vary based on age, but not health status.  For all other policies sold, CareFirst will ask questions about your health status and may turn you down based on your health conditions or health history.

• If you are HIPAA eligible, private insurance companies that sell individual health insurance must offer you the choice of at least two policies. Companies that do not designate two policies must offer you a choice of all their individual insurance policies. Policies sold to HIPAA eligible individuals cannot impose pre-existing condition exclusion periods. However, there is no limit on what you can be charged for this coverage.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible in the District of Columbia you are guaranteed the right to buy individual health insurance policies and are exempted from pre-existing condition exclusion periods. 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 plan, 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 D.C. law, newborns, adopted children, and children placed for adoption are automatically covered under the parents’ individual health insurance policy for the first 31 days, if the policy covers dependents. The insurer may require that the parent enroll the child (and pay the premium) within 31 days in order to continue coverage beyond the 31 days.
• If you have a disabled child, that child may remain covered under your fully insured group HMO plan after he or she reaches the age at which dependent coverage is usually terminated. To qualify, your son or daughter must be unable to work by reason of physical or mental impairment and must be chiefly dependent on the policyholder for support and maintenance..  Proof of dependency must be furnished within 31 days of reaching the time limit and may be required periodically thereafter.

What will my individual health insurance policy cover?

• It depends on what you buy. The District of Columbia does not require health insurers in the individual market to sell standardized policies. Insurers can design different policies and you will have to read and compare them carefully. For example, most individual market policies may provide only limited coverage for prescription drugs.  However, the District of Columbia does require all insurers to cover certain benefits - such as mammograms, prostate cancer screening, and diabetes treatment. Check with the D.C. Department of Insurance, Securities and Banking for more information about mandated benefits.
• If you are HIPAA eligible, individual insurers must offer you a choice of at least two state-approved policies, whose benefits must be similar to others they typically sell. At least one of those policies must offer comprehensive benefits. If two policies are not designated, you must be offered a choice of all of their individual insurance policies.

What about coverage for my pre-existing condition?

• No pre-existing condition exclusion periods or elimination riders can be imposed on your HIPAA guaranteed issue policy.
• Individual health insurers can impose elimination riders. This is an amendment to your health insurance policy that permanently excludes coverage for a health condition or even an entire body part or system.
• Individual insurers can also impose pre-existing condition exclusion periods. In D.C., there are no limits on how long an individual market insurer can apply a pre-existing condition exclusion period.

  The definition of pre-existing condition is different under individual health insurance than under group health plans. .  Individual health insurance can count as pre-existing any condition that was present before the first day of coverage, whether or not medical advice, diagnosis, care, or treatment was recommended or received before that first day.  Unlike group health plans, individual health insurers are not limited in how far back they can look for evidence of a pre-existing condition.  In D.C., pregnancy can count as a pre-existing condition, but not genetic information.

• Individual health insurers do not have to give you credit for your prior coverage.
• If you make a claim during the first three years of coverage, the insurer can look back from the time of your application to see if the claim is for a condition that would have been considered a pre-existing condition.  If the insurer, that the condition was pre-existing at the time of application, it can refuse to pay for expenses for that condition.

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

• If you have an expensive health condition, your individual health insurance premiums may be very high. The law does not prohibit District of Columbia health insurers from charging you more because of your health status, age and other factors.

• When you renew your individual health insurance policy, your premiums can increase based on certain factors, such as your age.

Can my individual health insurance policy be cancelled?

• Your 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 managed care plans, continue to live in the plan service area.
• Individual insurers sell temporary health insurance policies. Temporary policies are not guaranteed renewable. They will only cover you for a limited time, such as 6 months. 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 re-issued at all or at the same price.