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

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

• In general, insurers that sell individual health insurance in Missouri 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 they 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 MHIP coverage.
• However, if you are HIPAA eligible, private insurers cannot turn you down. All companies that sell individual insurance must offer you coverage. Insurers can offer you all of their individual health policies, their two most popular individual health insurance policies, or two policies specially designed for HIPAA eligible individuals - a “high” and a “low” option, whose benefits must be similar to those sold to everyone else. Companies that do not designate two policies must offer you a choice of all their individual insurance policies.

To be HIPAA eligible, you must meet certain criteria

No matter where you live in the U.S., if you are HIPAA eligible you are guaranteed the right to buy individual health coverage of some kind with no pre-existing condition exclusion periods.  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.

Your HIPAA eligible status ends as soon as you enroll in an individual health insurance policy, 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.

• In Missouri, newborns, adopted children, and children placed for adoption are automatically covered under the parents’ individual health insurance policy for the first 31 days, if the plan provides coverage for dependents. The insurer may require that the parent enroll the child within the 31 days in order to continue coverage beyond the 31 days.
• Under Missouri law, your disabled child may remain covered under your fully insured group plan into adulthood. This applies if your child was already disabled and covered under the plan before he or she reached the limiting age for dependent coverage. You will be required to submit proof of your child’s continued incapacity and dependency within 31 days following the date your child reaches the limiting age and periodically thereafter.

What will my individual health insurance policy cover?

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

What about coverage for my pre-existing conditions?

• If you are HIPAA eligible, no pre-existing condition exclusion periods can be imposed when buying an individual policy.
• However, if you are not HIPAA eligible, there are different ways individual health insurers can exclude a pre-existing condition. The insurer can impose an elimination rider. An elimination rider is an amendment to your health insurance contract that temporarily or permanently excludes coverage for a health condition, body part, or body system.

Also, an individual health insurer may impose a pre-existing condition exclusion period lasting up to 24 months.  If you make a claim during the first 24 months of coverage, your individual health insurer has the right to look back to see if the condition was pre-existing.  If it determines your condition existed prior to the effective date of the policy, it can refuse to pay the claim.

• 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.
• Unlike group health plans, individual health insurers do not have to give you credit for prior coverage.

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

• Generally, in Missouri, there are no limits on how much individual premiums can vary due to age, gender, health status, family size, 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, and premiums can also increase within limits as you age or your health declines.
• 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.