When do Individual Health Insurers have to sell me a policy?

In Maine, your ability to buy individual health insurance does not depend on your health status. 

• Insurers that sell individual health insurance in Maine are not permitted to turn you down because of your health status and other factors.
• In Maine, insurers that sell individual health insurance must offer family coverage to persons who are interested in purchasing it. Some HMOs may also offer husband-wife policies and parent-child(ren) policies.
• In Maine, newborns and newly adopted children are automatically covered under the parents’ individual health insurance policy for the first 31 days. The insurer may require that the parent enroll the child within the 31 days and pay the premium in order to continue coverage beyond the 31 days.
• If you are HIPAA eligible, you are guaranteed the same right to purchase individual health insurance as other individuals. However, individual health insurers cannot impose any pre-existing condition exclusion periods on the plan you purchase.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy an individual health insurance policy and are exempted from pre-existing condition exclusion periods.  In Maine, where state law is more protective, you do not need to meet all of the requirements of HIPAA eligibility to have this protection.  However, if you move out of Maine, this information may be important to you. 

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 HIPAA eligible.)
• You must apply for health insurance for which you are HIPAA 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 HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.

What will my Individual Health Insurance Policy cover?

• Maine requires that individual health insurers that choose to offer individual health insurance, and all HMOs, must offer a standardized policy to all consumers. You may select either the basic or standard policies. Non-standardized plans can be sold as well.

Standardized policies cover hospitalization, physician office visits, maternity care, prescription drugs, lab tests, limited rehabilitation services, and other care.  A choice of annual deductibles is offered, ranging from $250 to $1,500.

The Maine Bureau of Insurance issues a free buyer’s guide which lists plan options and the companies selling them.  This guide is available on the web at http://www.state.me.us/pfr/ins/indhlth.htm.

What about coverage for my pre-existing condition?

• If you are HIPAA eligible, individual health insurers are not permitted to apply pre-existing condition exclusion periods.
• If you are not HIPAA eligible and buy an individual health insurance policy, there are limits on pre-existing condition exclusion periods that can be imposed. Pre-existing condition exclusion periods cannot exceed 12 months. Individual health insurers can look back 12 months to see if you actually received care or treatment for a condition. This is called the objective standard.

In addition, you will get credit for prior continuous coverage that was not interrupted by a break of 90 or more days in a row (or 180 days, if you lost your prior coverage due to unemployment). 

• In Maine, pregnancy can be considered a pre-existing condition by individual health insurers and it can be excluded from coverage for 10 months. Genetic information cannot be considered a pre-existing condition.
• Individual health insurers are not allowed to impose elimination riders which permanently exclude coverage for a health condition, body part, or body system.

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

• Premiums for individual health insurance in Maine cannot vary due to your gender, health status, claims experience, or policy duration. Premiums may vary by as much as 20% above or below the community rate depending on your age, occupation, and smoking status. This is called modified community rating. Premiums also will vary based on family size, where you live in the state, and the type of plan you select. The buyer’s guide lists the community rate for each insurance company’s basic and standard plan. This guide is available on the web at http://www.state.me.us/pfr/ins/indhlth.htm.
• If you have low or modest income, you may be eligible to buy individual coverage for a reduced premium from Dirigo Health plan. See Financial Assistance for more information.

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.