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

In Oregon, 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 Oregon are free to turn you down because of your health status and other factors. When applying for an individual health insurance policy, 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 health insurance or offer to sell you a policy that has special limitations on what it covers.

However, under no circumstances can you be turned down, charged more or face a pre-existing condition 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 have had prior coverage, you may be eligible to buy a portability policy. Your protections under portability policies are described later on in this chapter.

· In addition, if you are turned down by an individual health insurer, you may be able to buy health insurance from the Oregon Medical Insurance Pool (OMIP). OMIP coverage is described later on in this chapter.

· In Oregon, newborns and adopted children are automatically covered under the parents’ individual health insurance policy for the first 31 days, if the policy covers dependents. The insurer may require that the parent enroll the baby within the 31 days in order to continue coverage beyond the 31 days.

What will my individual health insurance policy cover?

· It depends on what you buy. Oregon does not require health insurers in the individual market to sell standardized policies. Insurers can design different policies and you will have to read and compare them carefully. However, Oregon does require all individual health insurers to cover certain benefits – such as mammograms. Check with the Oregon Division of Insurance for more information about mandated benefits.

What about coverage for my pre-existing condition?

· If you can buy an individual health insurance policy, there are limits on pre-existing condition exclusion periods that can be imposed. In general, if you have been uninsured for more than 63 days before your individual health insurance policy becomes effective, you may face a 6-month pre-existing condition exclusion period.

Alternatively, an insurer may choose to impose a 90-day waiting period before coverage becomes effective. You will not have to pay a premium during the waiting period. Policies that require a 90-day waiting period cannot impose a pre-existing condition exclusion.

· Individual health insurance can count as pre-existing conditions only those for which you actually received (or recommended to receive) a diagnosis, medical advice, or treatment in the 6 months prior to obtaining the individual health insurance policy. Individual health insurance 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, insurer can still exclude coverage for a 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 insures can look back 6 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 my individual health insurance policy?

· In Oregon, your individual health insurance policy premiums can vary to reflect your age, benefit plans, family composition and geographic area, but not your health status or your genetic information. This is called modified community rating.

· When you renew your individual coverage, your premiums will increase based on your age.

Can my individual health insurance policy be canceled?

· Your policy 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 a managed care plan’s service area. However, your health policy may be canceled if the insurer does not continue to offer the coverage for all policyholders.

· 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 Oregon Insurance Division 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.