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

In Michigan, your ability to buy individual health insurance may depend on your health status.

• In general, individual health insurers, other than Blue Cross Blue Shield of Michigan, 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 have had in the past. Depending on your health status, insurers might refuse to sell you coverage or they may offer to sell you a policy that has special limitations on what it covers.
• Blue Cross Blue Shield of Michigan, by law, must sell individual health insurance to any resident. This is called guaranteed issue. In addition, HMOs must sell individual health insurance to any resident during the 30-day open enrollment each year. Check with your HMO for more information about open enrollment dates.
• Under Michigan law, newborns are automatically covered under the parents’ individual health insurance policy for the first 31 days, if the plan covers dependents. The insurer may require that the parent enroll the child and pay the required premium within in 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 policy holder for support. Proof of incapacity must be provided within 31 days of reaching the time limit. These requirements may vary depending on the type of health plan you are enrolled in. For more information contact the Michigan Office of Financial and Insurance Services.

What will my individual health insurance Policy cover?

• It depends on what you buy. Michigan does not require health insurers in the individual market to sell standardized policies. Health insurers can design different policies and you will have to read and compare them carefully. However, Michigan does require all individual health insurance policies to cover certain benefits-such as mammograms and diabetes care. Check with the Office of Financial and Insurance Services for more information about mandated benefits.

Michigan requires all HMOS to cover minimum benefits, including physician services, inpatient hospital care, emergency services, ambulance, and diagnostic laboratory and radiological services.

What about coverage for my pre-existing condition?

• If you are HIPAA eligible, Blue Cross and Blue Shield plans cannot impose a pre-existing condition exclusion period.

To be HIPAA eligible, you must meet certain criteria

No matter where you live, if you are HIPAA eligible you are guaranteed the right to buy an individual health plan with no pre-existing condition exclusion periods.   In Michigan, you are guaranteed the right to buy coverage only from Blue Cross Blue Shield of Michigan.  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 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 federally 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.

·           If you are not HIPAA eligible, the rules for pre-existing conditions in individual health insurance are somewhat different from those in group plans.  In general, you may face a 12-month pre-existing condition exclusion period.  However, if your coverage is through an HMO or Blue Cross Blue Shield, Michigan law limits the pre-existing condition exclusion period to 6 months.  Insurers can count as pre-existing any condition for which you received medical advice, care or treatment in the 6 months before individual coverage begins.  This is called the objective standard.  Individual health insurers are not required to credit your prior coverage toward this pre-existing condition exclusion period.

• Pregnancy may be considered a pre-existing condition in an individual health insurance policy. 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, the 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.

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

• If you have an expensive health condition, your individual health insurance premiums may be very high. In general, the law does not prohibit Michigan health insures from charging you more because of your health status, age, gender, and other case characteristics.
• Blue Cross Blue Shield of Michigan will not charge you higher premiums because of your health status. This is called community rating. Contact Blue Cross Blue Shield Michigan for information about coverage and premiums.
• When you renew your individual coverage, your premiums can increase as you age.

Can my individual health insurance policy be cancelled?

• 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.
• 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 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.