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

In Nevada, 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 Nevada 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 are HIPAA eligible, insurers must offer to sell you two standardized policies. You may select from either a basic or standard health benefit plan. You can choose the policy you want and cannot be turned down because of health status. You can be offered other non-standardized coverage as well, but you may be charged more for that coverage.
• In Nevada, you are also HIPAA eligible if your most recent prior creditable coverage was under a basic or standard health benefit plan and was not renewed by an insurer who discontinued offering and renewing individual health insurance policies in the state.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy individual health insurance 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.
• 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 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.

• Under Nevada law, 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 covers dependents. The insurer may require that the parent enroll the baby 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 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 and may be required periodically thereafter.

What will my Individual Health Insurance Policy cover?

• It depends on what you buy. Along with other policies, Nevada insurers are required to sell you two standardized policies. You may select from either a basic or standard health benefit plan. Standardized plans help you compare the cost of policies. You may be offered other non-standardized policies as well, but you may be charged more for that coverage
• The basic policy covers hospital, skilled nursing, rehabilitation, hospice, emergency care, physician services, laboratory and X-ray services, and prescription drugs. Services are covered with a 50% coinsurance. The lifetime maximum benefit is $1 million. The basic policy does not cover mental health services, substance abuse services, and maternity care.
• The standard policy covers everything that the basic policy covers. Those services are covered with a 20% coinsurance. In addition, the standard policy covers maternity care and limited mental health services, substance abuse services. The lifetime maximum benefit is also $1 million.
• Check with the Nevada Division of Insurance for more information about mandated benefits. You can also visit the Division’s website at http://doi.state.nv.us/ for the summary of benefits for individual basic and standard health benefit plans.

What about coverage for my pre-existing condition?

• If you are HIPAA eligible and purchasing a guaranteed issue individual health insurance policy, no pre-existing condition exclusion periods can be applied.
• 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. Elimination riders cannot be applied to HIPAA eligible individuals.
• Nevada insurers can also impose pre-existing condition exclusion periods. Except when you are HIPAA eligible or buying a conversion policy, there are few limits on pre-existing condition exclusion periods in individual health insurance in Nevada. This means that individual health insurers can decide how long to exclude your pre-existing condition.

Individual health insurance can count as pre-existing conditions only those for which you received a diagnosis, medical advice, or treatment in the 6 months period prior to obtaining the individual policy. Individual health policies can apply pre-existing condition exclusion periods for pregnancy, but not for genetic information.

• In addition, if you make a claim during the first 3 years your policy is in force, the insurer can refuse to pay that claim and others related to the condition if it determines the condition was pre-existing.

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

• In Nevada, there are limits on how much individual health insurance premiums can vary due to health status, age, gender, and other factors. Even within these limits, however, if you have a serious health condition, your premium may be significantly higher than the rate charged for other individuals. 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 Nevada Division of Insurance.

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.
• You health insurance policy may be canceled if the insurer discontinues your health policy or withdraws from the individual market.

If you are covered under a basic or standard individual policy and your insurance company discontinues this policy, all other individual health insurance companies must offer you coverage under their basic and standard policies.  You cannot be turned down and no pre-existing condition exclusion can be imposed if you apply within 63 days.

Call the Nevada Division of Insurance if you have questions about an insurance company or the renewability of individual health policies.

• Some insurance companies sell short-term health insurance policies. Short-term 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 short-term 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.