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

In Virginia, 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, companies that sell individual health insurance in Virginia (except for Anthem BlueCross BlueShield and Carefirst BlueCross BlueShield) are free to turn you down because of your health status and other factors. 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 to sell you coverage or offer to sell you a policy that has special limitations on what it covers.
• Anthem BlueCross BlueShield and CareFirst BlueCross BlueShield will sell individual health insurance to any Virginia resident regardless of health status. CareFirst serves northern Virginia, and Anthem serves other parts of the state. Policies you get from these companies cannot permanently exclude coverage for your pre-existing condition. Currently, Anthem imposes a 12 month pre-existing exclusion period and CareFirst imposes a 10 month pre-existing exclusion period. You will not receive credit for prior creditable coverage. Finally, rates for these plans are currently not based on health status but, depending on the insurer, may be adjusted for other factors such as age and location.
• If you are HIPAA eligible, private insurers cannot turn you down. Companies that sell individual insurance must let you purchase any of the individual market products that they sell. Policies sold to HIPAA eligible individuals cannot impose pre-existing condition exclusion periods. However, there is no limit on what you can be charged for this coverage.

To be HIPAA eligible, you must meet certain criteria

If you are HIPAA eligible you are guaranteed the right to buy individual health insurance 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.
• 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.

• Even if you are HIPAA eligible, insurance companies in Virginia are not required to offer you family coverage when you buy individual health insurance. They must, however, offer separate individual policies to each person in your family who is HIPAA eligible. Nonetheless, most insurance companies will voluntarily offer you family coverage if you request it.

• To be HIPAA eligible, you must meet certain criteria If you are HIPAA eligible you are guaranteed the right to buy an individual health plan 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. 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. You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage. Federal 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 Virginia, newborns, adopted children, and children placed for adoption 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.

• If you have a disabled child, that child may remain covered under your individual health insurance policy 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 policyholder for support. Proof of incapacity must be furnished within 31 days of reaching the time limit and may be required periodically thereafter, but not more than once every two years.

What will my individual health insurance policy cover?

• It depends on what you buy. Virginia 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, Virginia does require all health plans to cover certain benefits - such as mammograms and postpartum care. Check with the Virginia Bureau of Insurance for more information about mandated benefits.

What about coverage for my pre-existing condition?

• No pre-existing condition exclusion periods or elimination riders can be imposed on your individual health insurance policy if you are HIPAA eligible.
• Individual health insurers can impose elimination riders. 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.
• Virginia insurers can also impose pre-existing condition exclusion periods. Pre-existing condition exclusion periods cannot exceed 12 months.

The definition of pre-existing condition is different under individual health insurance than under group health plans.  Individual health policies can count as pre-existing any condition for which you received, or - in your insurer’s judgment, for which you should have sought - a diagnosis or medical advice or treatment in the 12-month period prior to obtaining the individual health policy.  This is called the prudent person rule.  Individual health policies can apply pre-existing condition exclusion periods for pregnancy, but not for genetic information.

• If you make a claim during the first two years of coverage, the insurer can look back 12 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 prudent person standard, that the condition is a pre-existing condition, it can refuse to pay for expenses for that condition.
• If a 12-month exclusion period is applied, you can get credit for any prior continuous creditable coverage you have had as long as you have not had a gap of 30 days or more between your old and new coverage.

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 Virginia health insurers from charging you more because of your health status.
• When you renew your individual health insurance policy, your premiums can increase based on certain factors, such as your age.

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 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 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.