When do private insurers have to sell me an individual policy?

· Individual health insurers, other than those offered by one of the regional Blue Cross and Blue Shield plans in Pennsylvania, are free to turn you down because of your health status and other factors.

· If you are HIPAA eligible, your only option for a guaranteed issue policy is through a Blue Cross and Blue Shield plan operating in your region. Other insurers are not required to sell you an individual health insurance policy on a guaranteed issue basis. However, you can still apply for an individual health insurance policy through another company and may be offered coverage if you are healthy.

· In Pennsylvania, newborns and adopted children 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 within the 31 days in order to continue coverage beyond the 31 days.

However, if the policy does not provide for coverage of dependents, the parent has the right to convert – within 31 days after the child’s birth- to a policy which will provide similar benefits.

· 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 obtaining self-sustaining employment because of physical handicap or mental retardation. Proof of incapacity must be furnished within 31 days of reaching the time limit.

What will my individual health insurance cover?

· It depends on what you buy. Pennsylvania does not require health insurers in the individual market to sell standardized policies. Health insurers can design different policies and you will have to read and compare them carefully. However, Pennsylvania does require all health plans to cover certain benefits – such as post-delivery hospital stays and breast cancer screening. Check with the Pennsylvania Department of Insurance for more information about mandated benefits.

· When you buy an individual health insurance policy in Pennsylvania, individual health insurers can require a probationary period before most of your coverage becomes effective. This period cannot exceed 30 days for non-accident-related conditions, or 6 months for certain procedures defined as elective. Accidental injuries will be covered immediately.

You can be charged a premium during this probationary period even though the insurer will not pay claims other than for accidental injuries during this time.

If your insurer requires a probationary period, the pre-existing condition exclusion period begins on the first day of the probationary period.

What about coverage for my pre-existing condition?

· There are different ways that 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 policy that temporarily or permanently excludes coverage for a health condition, body part, or body system.

An individual health insurer may also impose a pre-existing condition exclusion period. Pre-existing condition exclusion periods cannot exceed 36 months. If you make a claim during the first 3 years of coverage, your individual health insurer can look back 5 years to see if care or treatment for a condition was actually recommended or provided to you.

Pregnancy can be considered a pre-existing condition in all individual health insurance policies.

· Individual health insurers are not required to give you credit toward pre-existing condition exclusion periods for any prior continuous coverage.

What can I be charged for individual health insurance?

· If you have an expensive health condition, your individual health insurance premiums may be very high. The law does not prohibit Pennsylvania 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 health insurance 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 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 three 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 Pennsylvania 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.