When do individual health insurers have to sell me a Basic or Standard plan?           

• If you are HIPAA eligible and meet other requirements, you can buy either a basic or standard plan at any time during the year. You are always guaranteed the right to buy one of these policies from the insurer that covered you before you lost your group policy. You do not have to wait for an annual open enrollment period. In addition, all other individual insurers must offer you the option to buy either the basic or standard plan except those insurers that have met their annual enrollment cap.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible in Ohio you are guaranteed the right to buy a conversion policy or another individual health insurance policy. You are exempted from pre-existing condition exclusion periods. In addition, there are rules about what the plan must cover and what can be charged. 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.

• If you are not HIPAA eligible, you may be able to buy either a basic or standard plan during open enrollment. To buy either a basic or standard plan during an open enrollment period, you must not be eligible for any other group health plan, COBRA or state continuation coverage, or Medicare.
• Different types of individual insurers have different open enrollment periods. Indemnity health plans must have an open enrollment period beginning in January of each year. Managed care plans must have a 30-day open enrollment period each year as well, although the time of year may vary.

Generally, individual health insurers are required to advertise their open enrollment periods in newspapers at least 2 weeks prior to, and then throughout, their open enrollment periods.

• Even during open enrollment periods, individual health insurers are required to enroll only a limited number of people. Once a plan reaches its state-approved enrollment cap, it can refuse to sell you individual health insurance for that year. Also, plans are not required to enroll you if you are confined to a health care facility because of a chronic illness. A health insurer is also not required to hold open enrollment if the insurer is not financially sound.

What will my Basic or Standard plan cover?

• Basic and standard health plans must meet specific minimum standards as required under Ohio state insurance law. However, even with these standards, plans might vary slightly depending on the insurer and you will have to read and compare them carefully.
• A state board defines benefits that must be offered under basic and standard health plans and may change these definitions periodically. These descriptions that follow were current as of December 2004.

The standard health plan covers hospital and physician services, limited prescription drug benefits, and other health services.  Certain benefits, such as mental health care, maternity care, preventive services, and organ transplants, are subject to special limits.  Coverage for all services is limited to a lifetime maximum of $1 million.  An annual deductible of $750 applies.  Other cost sharing for covered services will vary depending on the type of plan you choose.  For example, some plans pay 80% for covered services and you pay 20%.  Others pay 60% and you pay 40%.  Benefits and cost sharing may be somewhat different in standard health plans offered by HMOs or HICs.

The basic health plan covers hospital and physician services, limited prescription drug benefits, and other health services.  Routine maternity care is not covered.  The basic health plan pays 50% of the cost of covered services after an annual deductible of $1,000.  All coverage is limited to $50,000 per calendar year.  In addition, special limits apply to coverage for certain services, such as mental health care, preventive services, and organ transplants.  Benefits and cost sharing may be somewhat different in basic health plans offered by HMOs or HICs.

What can I be charged for a Basic or Standard plan?

• Insurers are limited on how much they can charge you for either a basic or standard plan. If you are HIPAA eligible, there is a limit on what you can be charged. This limit works out to be about twice the rate charged to other people who do not come in through open enrollment.

If you are not HIPAA eligible, there also are limits on what you can be charged for basic and standard health plans during open enrollment.  Contact the Ohio Department of Insurance if you have questions about basic or standard plan premiums.

What about coverage for my pre-existing condition?

• Insurers are limited on how long they apply a pre-existing condition exclusion period under a basic or standard plan.

If you are HIPAA eligible and buy either a basic or standard plan, insurers cannot impose a pre-existing condition exclusion period.

If you are not HIPAA eligible and buy either a basic or standard plan during open enrollment, you may have a pre-existing condition exclusion period.  Individual health insurers can exclude coverage for pre-existing conditions for up to one year.  You must be given credit for any prior creditable coverage you had, provided no more than 30 days lapse between your old and new coverage.  Individual plans also can require a one-year waiting period before they will cover organ transplants.  However, newborn infants cannot be subjected to this waiting period for transplant coverage or any other benefit offered by the plan. HICs/HMOs are not allowed to apply pre-existing conditions to basic services such as maternity care.

Can my Basic or Standard plan be canceled?

• If you buy either a basic or standard health insurance plan, 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.