Individual Health Insurance Sold by Private Insurers

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

In New York, your ability to buy individual health insurance does not depend on your health status.

· Insurers that sell individual health insurance in New York are not permitted to turn you down because of your health status or other factors.

· Under New York law, newborns, adopted children, and children placed for adoption must be covered under your health insurance policy for the first 30 days following birth and adoption, if the policy covers dependents. The insurer may require that the parent enroll the child within 30 days in order to continue coverage beyond the 30 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 chiefly dependent on the policyholder for support and maintenance due to mental illness, developmental disability, mental retardation, or physical handicap. Proof of incapacity must be furnished to the insurer within 31 days of the child reaching the age at which dependent coverage would normally end.

· In New York, if your individual health insurance policy covers dependents, your adult child may be able to remain on your policy up to the age of 23 if he or she is unmarried and enrolled as a student at an accredited college.

· In New York, special protections apply if you have an adult child who is a full time student and who is covered under your individual health insurance policy. If your child becomes ill and must take a leave of absence from school, then the policy must allow your child to continue on your policy for up to one year. The rate the insurer charges you must be the same as if your adult child were still in school full time. The insurer is allowed to require that you provide it with certification from a physician to document the adult child’s illness.

· If you are HIPAA eligible, you are guaranteed the same right to purchase individual health insurance as other individuals. However, private insurers cannot impose any pre-existing condition exclusion periods on the policy you purchase.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy an individual health insurance policy and are exempted from pre-existing condition exclusion periods. In New York, where state law is more protective, you do not need to meet all of the requirements of HIPAA eligibility to have this protection. However, if you move out of New York, this information may be important to you. 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.

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.

What will my individual insurance policy cover?

· HMOs are required to offer a standardized policy to all consumers. You may select either the HMO or the point-of-service (POS) versions of the policy. Both versions offer comprehensive coverage, including hospital and physician care, maternity care, preventive checkups and immunizations, and prescription drugs.

The HMO policy option requires you to seek care only from doctors and hospitals that contract with the HMO. For a hospital stay and some other services, you will have to pay a deductible up to $500 before the policy begins to pay. Most other services require a copayment, although some services do not require a copayment at all.

The POS policy option lets you decide whether to get care from providers in or out of the HMO network. When you get care in-network, your out-of-pocket costs will be smaller – the same as they are under the HMO option. If you go out of network, your out-of-pocket costs will be higher. The policy will only pay 80% of covered charges once you have paid a $1,000 deductible. You will have to pay the other 20%, plus any extra amount billed by the provider.

· The New York Insurance Department issues a free guide called the New York Consumer Guide to Health Insurers which lists plan options and the companies selling them. Please visit at:

What about coverage for my pre-existing condition?

· If you buy an individual health insurance policy, there are limits on pre-existing condition exclusion periods that can be imposed. Pre-existing condition exclusion periods cannot exceed 12 months. Individual health insurers can look back 6 months to see if you actually received care or treatment for a condition.

· In New York, pregnancy can be considered a pre-existing condition in individual health policies, but insurers can only exclude it from coverage for 10 months. Genetic information cannot be considered a pre-existing condition.

· In New York, individual health insurers are not allowed to impose elimination riders, which permanently exclude coverage for a health condition, body part, or body system.

· You will get credit for prior continuous coverage that was not interrupted by a break of 63 or more days in a row. No pre-existing condition exclusion periods can be imposed on you if you are HIPAA eligible.

· If you make a claim during the first two 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 an individual health insurance policy?

· Premiums for individual health policies in New York cannot vary due to your age, gender, health status, or occupation. This is called community rating. Premiums may vary depending on your family size, where you live in the state, and the type of policy you select. However premiums cannot vary based on your genetic information. Check with the company for the most current premium rates.

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 you pay the premiums, do not defraud the company, and in the case of managed care plan, continue to live in the policy service area. However, guaranteed renewability does not protect you from having your premiums go up at renewal.

· However, 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 New York Insurance Department to learn more about your rights.

· 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 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.

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