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

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

· In general, companies that sell individual health insurance in Kansas 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 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 KHIA coverage.

However, under no circumstance can you be turned down, charged more or face a pre-existing exclusion period by a health insurance company 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, Kansas Health Insurance Association (KHIA) is your only guaranteed source of individual health insurance.

· In Kansas, newborns are automatically covered under the parents’ individual health insurance policy for the first 31 days if the individual health coverage was issued on a family basis, which means that it covers some other dependent, such as a spouse or a child. The insurer may require that the parent enroll the baby within the 31 days in order to continue coverage beyond the 31 days.

What will my individual health insurance policy cover?

· It depends on what you buy. Kansas 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, Kansas does require all individual health insurance policies to cover certain benefits – such as post-delivery hospital stays and breast cancer screening. Check with the Kansas 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 of 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 prior to purchasing coverage. In addition, insurers can count as pre-existing any condition that produced symptoms prior to the effective date 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 cannot be used as a basis for 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 individual health coverage?

· If you have an expensive health condition, premiums for your individual health insurance policy may be very high. The law does not prohibit Kansas health insurers from charging you more because of your health status. Premiums can also vary due to age, gender, family size, and other factors. In addition, when you renew your policy, your premiums can increase substantially as you age or if your health declines. However, premiums cannot vary based on your genetic information.

Can my individual health insurance policy be canceled?

· Your individual health insurance policy 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 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 Kansas Department 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.