When do individual health insurers have to sell me a policy?

In Delaware, your ability to buy individual health insurance depends on your health status.  There are certain circumstances, however, when you must be allowed to buy an individual health insurance policy.

• In general, insurers that sell individual health insurance in Delaware are free to turn you down because of your health status and other factors. When applying for individual coverage, 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.
• If you are HIPAA eligible, all insurance companies that sell individual insurance policies must offer you a choice of at least two policies.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible in Delaware you are guaranteed the right to buy an individual health insurance policy. You are exempted from pre-existing condition exclusion periods. In addition, there are rules about what the plan must cover and what can be charged. 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 Delaware law, newborns are automatically covered under the parent’s individual health insurance for the first 31 days, if the plan covers dependents. The insurer may require that the parent enroll the dependent within 31 days in order to continue coverage beyond the 31 days.

What will my individual health insurance policy cover?

• It depends on what you buy. Delaware does not require health insurers in the individual market to sell standardized policies. Health plans can design different policies and you will have to read and compare them carefully. Often, individual health insurance policies provide less comprehensive coverage than group plans, especially for certain services such as maternity care, mental health care and prescription drugs. Health plans are required to provide you with written descriptions of their products so that you can compare the differences.
• If you are HIPAA eligible, insurance companies must offer you a choice of two state approved policies with benefits similar to policies sold to everyone else. Companies that do not designate two policies must offer you a choice of all of their policies.

What about coverage for my pre-existing condition?

• There are different ways Delaware insurers are allowed to exclude coverage for your pre-existing conditions.

The insurer can impose an elimination rider.  This is an amendment to your health insurance contract that permanently excludes coverage for a health condition, body part, or body system.

An individual health insurer may also impose a pre-existing condition exclusion period. Generally, in Delaware, insurers can decide how long a pre-existing condition period will last. 

When determining if a condition is pre-existing, an individual health insurer is allowed to look back 5 years to see if you actually received care for a condition.  In addition, the insurer can look for evidence of symptoms of a condition before it was diagnosed for which most people, in the insurer’s opinion, would have sought care. This is called the prudent person standard.

Individual health insurers do not have to credit your prior continuous coverage against a pre-existing condition exclusion period.

• After you purchase your individual health insurance policy, insurers can still exclude coverage for a pre-existing condition, even if it wasn’t specifically excluded by the terms of the policy when you enrolled. If you make a claim during the first 2 years of coverage, the insurer can look back from the time of your application to see if the claim is for a condition that could be considered a pre-existing condition. If the insurer determines that the condition was a pre-existing condition, it can refuse to pay for related expenses.
• Pregnancy can 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 exclusion.
• If you are HIPAA eligible and buying a guaranteed issue policy, you will not face a pre-existing condition exclusion period.

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

• In Delaware, there are no limits on how much individual premiums can vary due to age, gender, health status, family size, and certain other factors.

Can my individual health insurance policy be canceled?

• If you have an individual health insurance policy, 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. However, guaranteed renewability does not protect you from having your premiums go up at renewal. Premiums can also increase within limits as you age.
• 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 six 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.