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

In Hawaii, 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 coverage.

• In general, companies that sell individual health insurance in Hawaii are free to turn you down because of your health status and other factors.
• If you are HIPAA eligible, private insurers cannot turn you down. Companies that sell individual insurance must offer you a choice of at least 2 plans that they sell.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy an individual health policy 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 federally eligible.)
• You must apply for health insurance for which you are federally 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 federally eligible again by maintaining continuous coverage and rejoining a group health plan.

• To be federally eligible, you must meet certain criteria If you are federally eligible you are guaranteed the right to buy an individual health plan and are exempted from pre-existing condition exclusion periods. To be federally 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. You must apply for health insurance for which you are federally eligible within 63 days of losing your prior coverage. Federal 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 federally eligible again by maintaining continuous coverage and rejoining a group health plan.

  In Hawaii, 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 within the 31 days in order to continue coverage beyond the 31 days.

• In Hawaii, adult dependents who are physically disabled or mentally retarded are able to stay on their parent’s individual health insurance policy after they have reached the age at which the health plan usually cancels dependent coverage. In order to be eligible, the adult dependent must be incapable of self-support and must be dependent on the policyholder for support. Proof of incapacity must be provided to the insurer within 31 days of reaching the limiting age.

What will my individual health insurance policy cover?

• It depends on what you buy. Hawaii does not require health insurers in the individual market to sell standardized policies. Health insurers can design different policies and you will have to read and compare them carefully. However, Hawaii does require all health plans to cover certain benefits - such as mammograms. Check with the Hawaii Insurance Division for more information about mandated benefits.

What about coverage for my pre-existing condition?

• If are purchasing individual health insurance as a HIPAA eligible individual, no pre-existing condition exclusion periods or elimination riders can be imposed on your individual health insurance policy.
• If you are not HIPAA eligible, 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 Hawaii law; however, insurers offering individual health insurance are generally limited to a three-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.

In Hawaii, pregnancy can be considered a pre-existing condition by individual health insurers, but genetic information cannot be considered a pre-existing condition in the absence of a diagnosis. 

What can I be charged for my 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 Hawaii health insurers from charging you more because of your health status. In addition, when you renew your individual coverage, your premiums can increase substantially as you age or if your health declines.

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.
• Some insurance companies sell short-term health insurance policies. Short-term 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 short-term 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.