When do individual health insurers have to sell me coverage?

In Kentucky, 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 insurance.

· In general, companies that sell individual health insurance in Kentucky are free to turn you down because of your health status and other factors. When applying for individual coverage, 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 Kentucky Access coverage.

However, under no circumstance can 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, Kentucky Access is your only guaranteed source of individual health insurance.

· In Kentucky, newborns are automatically covered under the parents’ individual health insurance for the first 31 days. The insurer may require that the parent enroll the baby and pay the premium within the 31 days in order to continue coverage beyond the 31 days.

· In Kentucky, mentally retarded and physically disabled dependents are permitted to remain insured under their parents’ individual health insurance after they reach the age at which dependent coverage is usually terminated, if certain conditions are met. The adult dependent must be incapable of self-support and must rely on the policyholder for support. In addition, proof of dependency and disability must be provided to the insurer within 31 days of the dependent reaching the limiting age.

What will my individual health insurance cover?

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

What about coverage for my pre-existing condition?

· Individual health insurers cannot impose elimination riders. An elimination rider is an amendment to your health insurance policy that permanently excludes coverage for a health condition, a body part, or a body system. Elimination riders are not allowed.

· Individual health insurers can count as pre-existing any condition for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice during the six-month period immediately before purchasing coverage. In Kentucky, an individual market insurer can apply a pre-existing condition exclusion period for up to 12 months. Pregnancy can be considered a pre-existing condition. However, genetic information cannot be used as a basis for a pre-existing condition.

· If you make a claim during the first three years of coverage, your 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, it can refuse to pay for expenses for that condition.

· Like group health plans, individual health insurers in Kentucky must give you credit for prior continuous coverage. Coverage counts as continuous if it is not interrupted by a break of 63 days or more.

What can I be charged for individual health insurance?

· All individual health insurance in Kentucky must limit how much premiums vary due to health status, age, and other factors. Even within these limits, however, if you have a serious health condition, your premiums may be significantly higher than the rates charged for other individuals. In addition, when you renew your individual coverage, your premiums can increase substantially as you age.

If you have questions about your premiums, contact the Kentucky Department of Insurance.

Can my individual health insurance 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 three 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 Kentucky 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 six 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.