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.

However, under no circumstance can you be turned down, charged more or face a pre-existing exclusion period by an individual insurer because of your genetic information. Genetic information includes the results of a genetic test and your family history of health conditions

· If you are 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, the Montana Comprehensive Health Association (MCHA) is your only guaranteed source of individual health insurance. 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. 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 three years prior to purchasing coverage.

· Pregnancy can be considered a pre-existing condition by individual health insurers. However, genetic information, provided that it is not favorable and provided voluntarily by the individual, cannot be used as the basis of a pre-existing condition.

· If you make a claim during the first two 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 Montana must give you credit for any prior continuous creditable coverage. Coverage counts as continuous if it is not interrupted by a break of 30 days or more in a row.

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

· If you have an expensive health condition, your individual health insurance premiums may be very high. The law does not prohibit Montana health insurers from charging you more because of your health status. However premiums cannot vary based on your genetic information.

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 Montana Insurance Division.

Can my individual health insurance policy 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, specific disease policies (such as those that cover only cancer) are not required to be guaranteed renewable in Montana.

Further, if you make a claim during the first two 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 Montana Office of the Commissioner of Securities and 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 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.