When do insurers have to sell me AN INDIVIDUAL INSURANCE POLICY?

In Wisconsin, 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 Wisconsin 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 have 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.
• If you have trouble buying private health insurance due to your health status, you may be eligible for HIRSP (see page 22).
• In Wisconsin, newborns, adopted children and grandchildren (provided the birth parent is a dependent under the age of 18) are automatically covered under the parents’ fully insured health plan for the first 60 days, if the plan covers dependents. The insurer may require that the parent enroll the child within the 60 days in order to continue coverage beyond the 60 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.

What will my individual health insurance POLICY cover?

• It depends on what you buy. Wisconsin 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, Wisconsin does require certain health plans to provide certain benefits - for example, annual mammograms for women 50 years or older. Check with the Wisconsin Department of Insurance for more information about mandated benefits.

What about coverage for my pre-existing condition?

• Individual health insurance 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.
• Wisconsin insurers can also impose pre-existing condition exclusion period. Pre-existing condition exclusion periods cannot exceed 2 years.

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 as determined by the plan, which existed anytime before the individual’s date of enrollment.  Unlike group health plans, individual health insurers are not limited in how far back they can look for evidence of a pre-existing condition.  In Wisconsin, pregnancy can count as a pre-existing condition, but not genetic information.

• If you make a claim during the first two years of coverage, the insurer can look back to see if the claim is for a condition that would have been considered a pre-existing condition. If the insurer determines that the condition is a pre-existing condition, it can refuse to pay for 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 a very expensive health condition, your health insurance premiums may be very high. Wisconsin insurance law does not prohibit insurers from charging you more because of your health status, gender, age, occupation, and other factors.
• 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.
• Your health insurance policy may be canceled if the insurer discontinues your health policy or withdraws from the individual market. Upon meeting other requirements, you may be eligible to buy an individual policy from HIRSP (see page 22).
• 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 6 months. If you want to renew coverage under a temporary policy after it expires, you will have to reapply for a new contract. There is no guarantee that coverage will be re-issued at all or at the same price.