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

In Georgia, your ability to buy individual health insurance depends on your health status. There are certain circumstances, however, when you must be allowed to buy a certain type of individual health insurance called a conversion policy.

· In general, companies that sell individual health insurance in Georgia 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 had in the past. Depending on your health status, insurers might refuse to sell you coverage or offer 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 recently left coverage under a group health plan and meet other requirements, you may be guaranteed the right to buy an enhanced conversion policy or a HIPAA assignment system policy.

· Under Georgia law, newborns, newly adopted children and children placed for adoption are automatically covered under an individual health insurance policy for the first 31 days after birth or adoption, if the policy provides dependent coverage. The health plan may require that the parent enroll the child and pay the premium within 31 days in order to continue coverage beyond the first 31 days.

· Under Georgia law, disabled adult children can remain on your individual health insurance policy after reaching the age at which dependent coverage usually ends, if they meet certain requirements. In order to be eligible, the adult dependent must be both incapable of self-support and chiefly dependent on the policyholder for support. Proof of incapacity must be provided to the health plan within 31 days of reaching the limiting age and may be required again in the future.

What will my individual health insurance policy cover?

· It depends on what you buy. Georgia 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. However, Georgia does require all health plans to cover certain benefits – such as mammograms and childhood immunizations. Check with the Georgia Office of Insurance for more information about mandated benefits.

What about coverage for my pre-existing condition?

· There are different ways an individual health insurer can exclude a pre-existing condition. The insurer can impose an elimination rider. An elimination rider is an amendment to your health insurance contract that temporarily or permanently excludes coverage for a health condition, body part, or body system.

· Also, an individual health insurer may impose a pre-existing condition exclusion period. There is no standard definition of pre-existing condition for the individual market under Georgia law; however, insurers offering individual health insurance are generally limited to a two-year period for pre-existing condition exclusions. Further, individual health insurers are not required to credit prior health coverage toward pre-existing condition exclusion periods.

· 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 make a claim during the first two years of coverage, the individual health insurer can look back to see if the claim is for a condition that would have been considered a pre-existing condition. If the insurer determines that the condition is a pre-existing condition, and you did not disclose it on your application, it can refuse to pay claims 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 Georgia health insurers from charging you more because of your health status. Premiums may be adjusted because of your age, gender and other non-health-status-based characteristics, subject to some restrictions by the state. However, premiums cannot vary based on your genetic information.

In addition, when you renew your individual coverage, your premiums can increase substantially as you age. However, you cannot be singled out for an increase in your premiums based on a change in your health status. Although, based on the claims experience of you and others in your plan, an insurer may increase premiums for all policy holders with that insurance plan on a statewide basis.

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 that the insurance company thinks is significant. 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 Georgia Office of Insurance to learn more about your rights.

· 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.