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

In Illinois, your ability to buy an individual health insurance policy from a private insurance company depends on your health status.

· In general, companies that sell individual health insurance in Illinois are free to turn you down because of your health status and other factors. When applying for an individual health insurance policy, 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. If you are turned down or offered a policy with reductions or restrictions, you may be eligible for CHIP coverage.

However, under no circumstance may you be turned down, charged more or face a pre-existing exclusion period by an individual insurers because of your genetic information. Genetic information includes the results of a genetic test and your family history of health conditions.

· If you are HIPAA eligible, Illinois Comprehensive Health Insurance Plan (CHIP) is your only guaranteed source of individual health insurance.

· Under Illinois law, newborns 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.

· If you have a dependent, disabled child, that child may remain covered under your individual health insurance policy after he or she reaches the age at which dependent coverage is usually terminated. As long as the person remains dependent because of a handicapped condition and cannot sustain employment, the individual can remain on your policy, provided that it remains in force.

What will my individual health insurance policy cover?

· It depends on what you buy. Illinois 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, Illinois does require all policies to cover certain benefits – for example, diabetes care and mammography screening. Check with the Illinois Department of Insurance for more information about mandated benefits.

What about coverage for my pre-existing condition?

· Individual health insurers can impose elimination riders. This is an amendment to your health insurance policy that permanently excludes coverage for a health condition, body part, or body system. Also, an insurer can impose an exclusion period for up to 24 months on any pre-existing condition.

The definition of pre-existing condition is different under individual health insurance than under group health plans. Individual health insurers can count as pre-existing any condition for which you received medical advice, care, treatment, or diagnosis in the 24 months prior to purchasing coverage. In addition, insurers can count as pre-existing any condition that produced symptoms within 12 months prior to the effective of coverage for which the insurer believes most people would have sought care. This is called the prudent person rule.

· Pregnancy can be considered a pre-existing condition by individual health insurers. However, genetic information, provided that it is not favorable and provided voluntarily by the individual, cannot be used as the basis of a pre-existing condition.

· If you make a claim during the first two years of coverage, your insurer can look back as far as 24 months 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 that the condition is a pre-existing condition, it can refuse to pay for expenses for that condition.

· Unlike group health plans, individual health insurers do not have to give you credit for prior coverage.

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

· Generally, in Illinois, there are no limits on how much individual premiums can vary due to age, gender, health status, family size, and other factors. 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. Generally, 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, and premiums can also increase within limits as you age or your health declines.

Further, 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 Illinois Department of Insurance to learn more about your rights.

· Some 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.