Individual Health Insurance Sold by Private Insurers

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When do Individual Health Insurers have to sell me a policy? 

In Rhode Island, 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 an individual health insurance policy.

  • In general, companies that sell individual health insurance in Rhode Island are free to turn you down because of your health status and other factors when you are uninsured. 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 you coverage or offer to sell you a policy that has special limitations on what it covers.
  • In some circumstances, you may be eligible for a guaranteed issue policy. If you have 12 months of prior creditable coverage with no gap, all insurance companies that sell individual health insurance must offer you a choice of at least two policies whose benefits must be similar to those sold to everyone else. You cannot be turned down because of your health status.
  • In addition, if you are HIPAA eligible, all insurers that sell individual health insurance policies must offer you a choice of at least two policies.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy an individual health insurance policy and are exempted from pre-existing condition exclusion periods.  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. (Note: Creditable coverage for purposes of federal law is somewhat different from Rhode Island law. Consult the consumer guide for the state you are moving to for more information.)
  • 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.

In Rhode Island, you do not need to meet all of these requirements in order to have protections when buying individual coverage.  If you plan on leaving Rhode Island, you may need to be HIPAA eligible to be guaranteed the right to buy individual health insurance in another state.

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  • Blue Cross/Blue Shield of Rhode Island is required to offer individual health insurance to any resident on a guaranteed issue basis during a 30-day annual open enrollment period (Aug. 15- Sept. 15 for 2006). Guaranteed issue policies will not impose any pre-existing condition exclusion period. In addition, premiums for these polices will be based on community rating.
  • Other policies sold by Blue Cross/Blue Shield do not offer these protections. You might be turned down or charged more based on your health status and policies may exclude coverage for pre-existing conditions.
  • Under Rhode Island law, newborns and adopted children are automatically covered under their parents’ individual health insurance policy for the first 31 days after birth or the start of the adoption bonding period. The insurer may require that the parent enroll the child within the 31 days in order to continue coverage beyond the 31 days
  • Under Rhode Island law, adult dependents who are physically disabled or mentally retarded are, at the option of the insured, able to stay on their parents’ fully insured group health plan or be issued a separate conversion policy after they have reached the age at which the plan usually cancels dependent coverage. In order to be eligible, the adult dependent must be incapable of self-support and must be dependent on the policyholder for support. Proof of incapacity must be provided to the insurer within 31 days of reaching the limiting age.

What will my individual health insurance policy cover?

  • It depends on what you buy. Health insurance companies design policies and you will have to read and compare them carefully. However, Rhode Island does require all health plans to cover certain benefits - such as treatment for diabetes and post-delivery hospital stays. Check with the Rhode Island Insurance Division for more information about mandated benefits.

What about coverage for my pre-existing condition?

  • If you buy an individual policy on a guaranteed issue basis, either because you have 12 months of prior continuous coverage or are HIPAA eligible, you will not face a pre-existing condition exclusion period.
  • If your policy is not guaranteed issue, there are different ways that individual health insurance 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.  The policy can also include a 12-month pre-existing condition period on any pre-existing condition.

Pre-existing conditions are any conditions for which you received medical advice, care or diagnosis in the last 36 months.  In addition, insurers can count any condition for which the plan believes most people would have sought care. This is called the prudent person rule.  If you make a claim for treatment of a condition during the first year of coverage under our individual policy, your insurance may investigate your medical records for evidence that the condition was pre-existing.

In Rhode Island, pregnancy can be considered a pre-existing condition in individual health insurance.  However, genetic information cannot be considered a pre-existing condition in the absence of a diagnosis.

  • Blue Cross & Blue Shield of Rhode Island typically imposes shorter pre-existing condition exclusions or does not impose them at all.

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

  • Generally, in Rhode Island, there are no limits on how much individual premiums can vary due to age, gender, health status, family size and other factors, when policies are first issued or at renewal.

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 short-term (or temporary) health insurance policies. Short-term 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 short-term 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. If you purchase a short-term policy, you should keep in mind that it will not count for purposes of guaranteed issue if it was the last policy you had.


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