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

In Ohio, 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 Ohio 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, there are certain times of year that you cannot be turned down because of your health status, age, or any other factor that might predict your use of health services. This is called guaranteed issue.  During open-enrollment periods, insurers must sell you either a basic or standard plan. 

In addition, if you are HIPAA eligible, you are guaranteed the right to purchase either a basic or standard plan.

There are special rules that apply to this these plans (see below).

• In Ohio, newborns, adopted children and children placed for adoption are automatically covered under the parent’s individual health insurance policy days, if the plan covers dependents. The insurer may require that the parent enroll the dependent within 31 days in order to continue coverage beyond the 31 days.
• In Ohio, if your individual health insurance policy covers dependents, disabled dependents may be permitted to remain insured after they reach the age at which dependent coverage is usually terminated. The adult dependent must be unmarried, incapable of self-sustaining employment by reason of mental retardation or physical handicap and must rely on the policyholder for support. In addition, proof of dependency and disability must be provided to the insurer within 31 days of the dependent reaching the limiting age and periodically after that.

What will my individual health insurance policy cover?

• It depends on what you buy. Individual health insurers can design policies and you will have to read and compare them carefully. However, Ohio does require all health plans to cover certain benefits - such as treatment for diabetes and post-delivery hospital stays. Check with the Ohio department of Insurance for more information about mandated benefits.

  What about coverage for my pre-existing condition?

• If you buy an individual health insurance policy then there are different ways that insurers can exclude a pre-existing condition.

The insurer can impose an elimination rider, which is an amendment to your health insurance contract that permanently excludes coverage for a health condition, body part, or body system. Or a plan can impose a 12 month pre-existing condition period on any pre-existing condition.

Insurers can count as pre-existing any condition for which you received - or, in your insurer’s judgment, for which you should have sought - medical care, treatment, diagnosis or advice in the 6-month period prior to enrollment.  This is called the prudent person rule.

If an insurer imposes a pre-existing exclusion period, it must give you credit toward the pre-existing condition exclusion period for any prior creditable coverage you had, provided no more than 30 days lapse between your old and new coverage.

• Generally insurers cannot consider genetic information as pre-existing condition. However, it is important to note the definition of “genetic information” is defined more narrowly than employer sponsored group plans.
• Pregnancy can be considered a pre-existing condition under individual policies. Also, except in guaranteed issue policies, insurers can exclude coverage for maternity benefits - whether or not you are pregnant when you buy the policy - for up to the first 270 days you are enrolled.
• HICs/HMOs are not allowed to have pre-existing condition exclusion periods for basic health care services.

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

• In Ohio, premiums must relate to the benefits offered. However, generally there are no limits on how much insurers can vary premiums for non-guaranteed issue policies due to age, gender, health status, family size, and certain other factors.

Can my individual health insurance policy be canceled?

• If you have an individual health insurance policy, 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. However, guaranteed renewability does not protect you from having your premiums go up at renewal, premiums can also increase within limits as you age.
• 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.