This section discusses the protections that apply to indemnity plans.  The protections that apply to individual coverage offered by HMOs are different from those applicable to indemnity plans, but no HMOs in Oklahoma offer individual coverage at the time of this guide’s writing.

When do individual health insurers have to sell me an individual health insurance policy?

In Oklahoma, your ability to buy individual health insurance depends on your health status. 

• In general, companies that sell individual health insurance in Oklahoma 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. If you are turned down or offered a policy with reductions or restrictions, you may be eligible for the Oklahoma Health Insurance High Risk Pool. (See below.)
• In Oklahoma, newborns 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 child and pay the premium within the first 31 days in order to continue coverage beyond the first 31 days.

What will my individual health insurance policy cover?

• It depends on what you buy. Oklahoma 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, Oklahoma does require all health plans to cover certain benefits - for example, mammograms and childhood immunizations. Check with the Oklahoma Insurance Department for more information about mandated benefits.

What about coverage for my pre-existing condition?

• There are different ways an individual health insurer can exclude a pre-existing condition. The insurer can impose an elimination rider. An elimination rider is an amendment to your health insurance contract that temporarily or permanently excludes coverage for a health condition, body part, or body system.

Also, an individual health insurer may impose a pre-existing condition exclusion period. There are no legal limits on how long a pre-existing condition exclusion can last. The duration of a pre-existing condition exclusion period is determined by the individual health insurer.

In addition, there is no standard definition of pre-existing condition for the individual market under Oklahoma insurance law.  Often, the definition is a condition for which you received care, or - in the insurer’s judgment - for which you should have sought care.   This is called the prudent person rule.  Further, individual health insurers are not required to credit prior health coverage toward pre-existing condition exclusion periods.

• Pregnancy may be considered a pre-existing condition in an individual health insurance policy. However, genetic information cannot be used as a basis for a pre-existing 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 individual health insurers from charging you more because of your health status.

In addition, when you renew your individual coverage, your premiums can increase substantially as you age or if your health declines.

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.
• 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 6 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.