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

• In general, private insurers can refuse to sell you individual health insurance because of your health status, your occupation, or other reasons. There are some important exceptions to this, however.
• Private insurers in Utah must accept individuals who are not eligible for certain types of private or public insurance. Private insurers are not required to offer you a policy if you have or are able to get health insurance through your job, an association that you belong to, COBRA continuation coverage, state continuation coverage, conversion coverage, Medicare, Medicaid, or HIPUtah. If you have been turned down for coverage by HIPUtah, private insurers are required to sell you a basic plan.
• If you have trouble buying private health insurance due to your health status, you maybe eligible for HIPUtah.
• Under Utah law, newborns, adopted children and children placed for adoption are automatically covered under the parents’ individual health insurance policy for the first 30 days, if the plan covers dependents. The insurer may require that the parent enroll the child and pay a premium within 30 days of birth or placement in order to continue coverage beyond the first 30 days. For newborns placed for adoption, this coverage is backdated to the date of birth, if the child is placed for adoption within 30 days of birth.
• If you have a disabled child, that child may remain covered under your fully insured group health plan after he or she reaches the age at which dependent coverage is usually terminated. To qualify, your adult son or daughter must be incapable of self-support because of mental retardation or physical disability and must be chiefly dependent on the policy holder for support. Proof of incapacity must be furnished within 30 days of reaching the time limit and may be required periodically thereafter, but no more frequently than once every 2 years after that.

What will my Individual Health Insurance Policy cover?

• Utah requires health insurers in the individual market to offer standardized policies in addition to the other policies they sell. Indemnity, preferred provider organization (PPO), and HMO versions of the standardized policies are available. If you buy standardized policies, you will be able to pick a low, medium, or high deductible level. Standardized policies cover hospitalization and doctor services, but do not cover routine pregnancy care. They provide some coverage for mental health and chemical dependency after a 12-month probationary period. Standardized policies make it easier for you to compare the prices that different companies charge. Non-standardized policies can also be offered to you, and you will have to read and compare them carefully.
• Utah also requires all health insurance products to cover certain benefits - such as breast reconstruction following mastectomy. (Check with the Utah Department of Insurance for more information about mandated benefits.)

What about Coverage for my Pre-existing Condition?

• There are different ways insurers are allowed to limit coverage for your pre-existing conditions.
• The insurer can impose an elimination rider for some conditions. This is an amendment to your health insurance policy that permanently excludes coverage for a health condition or even an entire body part or system. Elimination riders can be applied even if you have prior creditable coverage. If you are eligible for the basic plan, insurers may not impose elimination riders. The Utah Insurance Department maintains a list of conditions that insurers can exclude from your policy. Contact the Insurance Department if you have questions about an elimination rider.

An individual health insurer may also impose a pre-existing condition exclusion period. Pre-existing condition exclusion periods cannot exceed 12 months.   

When determining if a condition is pre-existing, an individual health insurer is allowed to look back 6 months to see if you actually received medical advice, diagnosis, or treatment for a condition. This is called the objective standard.  In Utah, pregnancy can count as a pre-existing condition, but not genetic information.

• When you buy a new individual health policy, the law protects you from a new pre-existing condition exclusion period, provided you maintain continuous creditable coverage. For individual health insurance, prior coverage is creditable if it was from a private or public health plan that provided similar benefits. Coverage counts as continuous if it is not interrupted by a break of 63 or more days in a row. Individual insurers do not have to give you credit for specific conditions that were excluded from any prior individual coverage because of an elimination rider.
• If you are HIPAA eligible and you buy individual health insurance because HIPUtah enrollment is closed, insurers cannot apply a pre-existing condition exclusion period.

What can I be charged for an Individual Health Insurance policy?

• If you are buying an individual health insurance policy, there are limits on what you can be charged because of health status, age, or other characteristics. Even with these limits, expect to pay substantially more for a policy if you have health problems or are over the age of 50.
• When you renew your individual health insurance policy, your premiums can increase substantially as you age or if your health declines. Contact the Utah Insurance Department with questions about your individual health insurance premiums.

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 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 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.