WHEN DO INDIVIDUAL HEALTH INSURERS HAVE TO SELL ME A POLICY?

In Montana, 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, insurers that sell individual health insurance in Montana 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 offer to sell you a policy that has special limitations on what it covers.
• If you have been denied coverage because of your health status, you can buy individual health insurance from the Montana Comprehensive Health Association (MCHA).
• If you are HIPAA eligible, you can buy individual health insurance from MCHA. You will not have a pre-existing condition exclusion period. There are limits on what you can be charged.
• In Montana, 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.
• If you have a disabled child, that child may remain covered under your individual health insurance 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 policyholder for support. Proof of incapacity must be furnished to the insurer within 31 days of reaching the limiting age and may be required subsequently in the future.

What will my Individual health insurance policy cover?

• Montana requires that insurers offer a uniform health benefit plan to all consumers. This plan is intended to be a less expensive policy because coverage under it is relatively sparse. The uniform plan requires a 50% coinsurance with a $1,000 deductible, a stoploss of $5,000, and a lifetime maximum of $1 million. The uniform plan also does not cover some mandated benefits - such as rental or purchase of durable medical equipment - that Montana requires all other individual health insurance policies to cover.
• Insurers are free to design other, non-standardized policies and offer them as well. Montana does require all health plans to cover certain benefits such as hospital services and professional services for the diagnosis or treatment of injuries, illness, or conditions, other than dental.
• Check with the Montana Division 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 or even an entire body part or system.
• Individual health insurers can also impose pre-existing condition exclusion period. Pre-existing condition exclusion periods cannot exceed 12 months. If a 12-month exclusion period is applied, you can get credit for any prior continuous creditable coverage you have had as long as you have not had a gap of 30 days or more between your old and new coverage.

The definition of pre-existing condition is different under individual health insurance than under group health plans.  Individual health insurance can count as pre-existing any condition for which you received a diagnosis, medical advice, or treatment in the 3 years prior to obtaining the individual health policy.  In Montana, individual health insurers can count pregnancy