When do individual health insurers have to sell me a policy?
In Florida, 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, insurers that sell individual health insurance in Florida 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, you cannot be denied a policy based on a history of breast cancer if you have been free of breast cancer for at least two years. Insurers can turn you down based on a history of other types of cancer or for other reasons.
In addition, under no circumstance may 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 had at least 3 months of coverage under a fully insured group health plan and then lose it, you are guaranteed the right to buy a conversion policy. Insurers must offer you a choice of at least two policies. You will not have a new pre-existing condition exclusion period.
· If you are HIPAA eligible but do not qualify for a conversion policy, you are guaranteed the right to buy an individual health policy from any insurance company that sells such policies in Florida. Insurers must offer you a choice of at least two policies.
To be HIPAA eligible, you must meet certain criteria
If you are HIPAA eligible you are guaranteed the right to buy individual health insurance in every state and are exempted from pre-existing condition exclusion periods. In Florida, if your most recent coverage was under a fully insured group plan, you can buy a conversion policy. If not, you can buy individual coverage from any insurer in the state that offers 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.
· Certain other people who lose other health insurance, may be eligible to buy a guaranteed-issue individual health insurance policy. If your individual health insurer or HMO terminated your coverage due to insolvency, dropped all individual coverage in Florida, or if you moved out of your individual health insurer’s service area, other insurers must offer you individual coverage regardless of your health status.
· Under Florida law, newborns, newly adopted children and children placed for adoption, are automatically covered under the parent’s individual health insurance policy for the first 30 days if the policy covers dependents. The insurer may require that the parent enroll the child within the 30 days in order to continue coverage beyond the 30 days.
· If you have a disabled child, your child may remain covered under your individual health insurance after he or she reaches the age at which dependent coverage is usually terminated, if they meet certain requirements. To qualify, your adult son or daughter must be incapable of self-support because of mental retardation or physical disability and chiefly dependent on the policyholder for support.
What will my individual health insurance policy cover?
· It depends on what you buy. Florida 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. However, Florida does require all health insurers to cover certain benefits – such as childhood immunizations, mammograms, and diabetes treatment. Check with the Florida Department of Financial Services for more information about mandated benefits.
What about coverage for my pre-existing condition?
· If you are HIPAA eligible and purchasing a guaranteed issue individual health insurance policy, no pre-existing condition exclusion periods can be applied.
· 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 health policies cannot impose an elimination rider for breast cancer unless you have been treated for it within the past two years. Elimination riders cannot be applied to HIPAA eligible individuals. In addition, insurers cannot impose riders based on a diagnosis of breast cancer if you have been free of breast cancer for at least two years.
· Florida insurers can also impose a pre-existing condition exclusion period. Pre-existing condition exclusion periods cannot exceed 2 years.
The definition of pre-existing is different under individual health insurance than under group health plans. Individual health insurance can count as pre-existing conditions only those for which you received, or – in your insurer’s judgment, for which you should have sought – a diagnosis or medical advice or treatment in the 2-year period prior to obtaining the individual health policy. This is called the prudent person rule. Individual health policies can apply pre-existing condition exclusion periods for pregnancy, but not for genetic information.
If a 2-year exclusion period is applied, you can get credit for any prior continuous creditable coverage you have had as long as you have not had a gap of 62 days or more between your old and new coverage. In order for your prior coverage to count as creditable coverage it must be similar or more comprehensive than your new policy.
· If you make a claim during the first 2 years of coverage, the insurer can look back 2 years 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 determines, using the prudent person standard, that the condition is a pre-existing condition, 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 Florida health insurers from charging you more because of your health status, age, gender, and other case characteristics. However premiums cannot vary based on your genetic information.
Can my individual health insurance policy be canceled?
· 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 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 Florida Office Of Insurance Regulation to learn more about your rights.
· Your health insurance policy may be canceled if the insurer discontinues your health policy or withdraws from the individual market. Upon meeting other requirements, you may be eligible to buy an individual policy in the individual market. (see above)
· 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.
