WHEN DO individual health INSURERS HAVE TO SELL ME a policy?

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

• In general, insurers that sell individual health insurance in Iowa 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 to sell you a policy with special limitations on what it covers. If this happens, you can buy health insurance from Iowa’s Comprehensive Insurance Association (HIP-IOWA).
• In Iowa, newborns, adopted children, and children placed for adoption are automatically covered under the parents’ individual health plan for the first 31 days, if the plan provides coverage for dependents. The insurer may require that the parent enroll the child and pay the premium within the 31 days in order to continue coverage beyond the 31 days.
• If you have a 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. To qualify, your adult son or daughter must be incapable of self-support because of mental retardation or physical disability and must be chiefly dependent on the policyholder for support. Proof of incapacity must be furnished to the insurer within 31 days of reaching the limiting age and may be required subsequently in the future.

WHAT WILL my individual HEALTH insurance policy COVER?

• It depends on what you buy. Iowa does not require health insurers in the individual market to sell standardized policies, except in certain situations (see below). Health plans can design different policies and you will have to read and compare them carefully. Often, individual health polices provide less comprehensive coverage than group health plans, especially for certain services such as maternity care, mental health care, or prescription drugs. However, Iowa does require all health plans to cover certain benefits - such as cancer screening and diabetic supplies and services. Check with the Iowa Division of Insurance for more information about mandated benefits.

WHAT ABOUT coverage for MY PRE-EXISTING CONDITION?

• There are different ways that individual health insurers can exclude a pre-existing condition.

The insurer can impose an elimination rider, which is an amendment to your health insurance contract that permanently excludes coverage for a health condition, body part, or body system. Or an insurer can impose a pre-existing condition exclusion period up to 24 months on any pre-existing condition.

In Iowa, a pre-existing condition is any condition which existed within the five years prior to obtaining an individual health insurance policy- whether or not if was diagnosed- for which the insurer believes most people would have sought care.  This is called the prudent person standard.

In addition, any time you make a claim within the first two years after the effective date of the policy, your individual health insurer has the right to look back to see if the condition was pre-existing.  If the insurer finds evidence your condition was pre-existing, it can refuse to pay the claim.

• Unlike group health plans in Iowa, individual health insurers do not have to give credit for your prior coverage.
• Pregnancy can be considered a pre-existing condition by individual health insurers.
• Genetic information collected as a result of a health condition that has already been diagnosed can be used by insurers to determine whether a pre-existing condition exists.

WHAT CAN I BE CHARGED FOR an INDIVIDUAL HEALTH INSURANCE policy?

• There are limits on how much individual health insurers can increase your premiums based on your health status. Even within these limits, your premiums can be significantly higher if you have a serious health condition. In addition, your premiums may be higher based on your age, gender, occupation and other factors.

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, guaranteed renewability does not protect you from having your premiums go up at renewal.
• Some insurance companies sell short-term (or temporary) health insurance policies. Short-term policies are not 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, you will have to reapply and there is no guarantee that coverage will be re-issued at all or at the same price. In addition, pre-existing conditions are never covered by short-term (or temporary) health insurance policies.