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

In West Virginia, your ability to buy individual health coverage may depend on your health status.  There are certain circumstances, however, when you must be allowed to buy individual health coverage.

• In general, companies that sell individual health insurance in West Virginia are free to turn you down because of your health status and other factors. When applying for individual coverage, 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.
• HMOs in West Virginia may have an annual open enrollment period. During this period, you can buy individual coverage without regard to your health status.
• If you have trouble buying private health insurance due to your health status, you may be eligible for AccessWV (see page 24).
• If you are HIPAA eligible, you are guaranteed the right to buy either an individual health insurance policy from any insurance company that sells such policies in West Virginia, or coverage from AccessWV (see page 24). Individual health insurers 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 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. (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.

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.

• Under West Virginia law, newborns and adopted children and children placed for adoption are automatically covered under the parents’ fully insured 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 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.

What will my individual health insurance policy cover?

• It depends on what you buy. West Virginia 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, West Virginia does require all health plans to cover certain benefits - such as childhood immunizations. Check with the West Virginia Insurance Commission for more information about mandated benefits.

What about coverage for my pre-existing condition?

• If you are HIPAA eligible and purchasing a guaranteed issue individual health insurance policy, no pre-existing condition exclusion period can be applied.
• 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.
• West 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 insurance can count as pre-existing any condition for which you received or, in your insurance company’s judgment for which most people would have sought medical advice, care or treatment in the 2 years before individual coverage begins. This is called the prudent person rule. Individual plans cannot impose pre-existing condition exclusion periods on newborns, newly adopted children, or children placed for adoption covered within 31 days, but they can impose pre-existing condition exclusion periods on pregnancy.
• If you make a claim during the first 2 years of coverage, the insurer can look back 2 years from the time of your application to see if your 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 the expenses for that condition.
• Unlike group health plans, individual health insurers do not have to give credit for your prior 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 West Virginia health insurers from charging you more because of your health status, age gender, and other case characteristics.
• When you renew your individual coverage, your premiums can increase as your age increases.

Can my individual health insurance policy be cancelled?

• 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 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.