When do individual health insurers have to sell me a policy?
In North Carolina, 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, companies that sell individual health insurance in North Carolina are free to turn you down because of your health status and other factors. When applying for individual coverage, 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 may you be turned down, charged more or face a pre-existing exclusion period because of your genetic information. Genetic information includes the results of a genetic test and your family history of health conditions.
· If you are HIPAA eligible, all private insurance companies that sell individual health insurance must offer you a choice of at least two plans, 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. Policies sold to HIPAA eligible individuals cannot impose pre-existing condition exclusion periods. However, there is no limit on what you can be charged for this coverage.
To be HIPAA eligible, you must meet certain criteria:
If you are HIPAA eligible you are guaranteed the right to buy individual health insurance and are exempted from 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.
HIPAA eligibility ends when you enroll in an individual plan, 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 North Carolina, newborns, adopted children and grandchildren (provided the birth parent is a dependent under the age of 18) are automatically covered under the parents’ fully insured health plan for the first 30 days, if the plan covers dependents. The insurer may require that the parent enroll the child within the 30 days in order to continue coverage beyond the 30 days.
· If you have a disabled child, he or she may remain covered under your individual health insurance policy after 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 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. North Carolina 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, North Carolina does require all health plans to cover certain benefits – such as mammograms, and prostate cancer screenings. Check with the North Carolina Department 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.
· North Carolina 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 63 days or more between your old and new coverage. No pre-existing condition exclusion periods can be applied if you are HIPAA eligible.
· Individual health insurance can count as pre-existing conditions only those for which you actually received (or were recommended to receive) a diagnosis, medical advice, or treatment in the 12 months prior to obtaining the individual health policy. Individual health policies can count pregnancy as a pre-existing condition, but not genetic information.
· Individual health insurers that impose pre-existing condition exclusion periods must give credit for any previous continuous creditable coverage. Most types of private and government sponsored health coverage are considered to be creditable coverage. Coverage counts as continuous if it has not been interrupted by a break of 63 or more days in a row.
· After you purchase your individual health insurance policy, insurers can still exclude coverage for pre-existing condition even if it was not specifically excluded in the terms of the policy. If you make a claim during the first two years of coverage, the insurer can look back 12 months from the time of your application to see if the claim is for a condition that would have been considered a pre-existing condition. If the insurer determines, using the objective standard, 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?
· If you have an expensive health condition, your individual health insurance premiums may be very high. The law does not prohibit North Carolina health insurers from charging you more because of your health status and other factors. However premiums cannot vary based on your genetic information.
· When you renew your individual coverage, your premiums will increase based on your age.
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. Coverage may be canceled should the carrier leave the market after appropriate notice or membership ceases in certain kinds of association groups
· 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 North Carolina Department of Insurance 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 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.
