 | | | Frequently Asked Questions:
Individual Health Coverage
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1) What is individual health coverage? |
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| When you have individual health coverage, you pay a private company a premium to be part of a health plan. If you pay your premiums and other costs, the company will help pay for medical costs that they have agreed to cover. |
2) What is the difference between individual coverage and employer-sponsored coverage? |
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Unless you meet certain rules, individual policies can take your health status into consideration when they decide whether or not to cover you. You are responsible for the entire cost of the premium. Employer-sponsored policies can't take your health status into consideration when you are signing up. Your employer may contribute a portion or the entire cost of your premium. The rules for policies offered through unions and professional organizations depend on the details of the organization and the policy. |
3) How do you obtain individual health coverage? |
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You can buy Individual policies through insurance companies, agents or brokers. Unless you meet certain rules, eligibility is based on your past and current health conditions. You can purchase this type of health coverage for yourself and/or your dependants. If it's available to you, health coverage from employers or professional organizations may be better options than individual coverage. |
4) Who is eligible for individual health coverage? |
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Unless you meet certain rules, when you apply for individual coverage, the insurance company will review your medical history and decide if they will cover you and how much your policy will cost. This process is called medical underwriting. If you have a medical condition, you may be denied coverage or have to pay high prices. |
5) What types of individual health coverage are there? |
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6) Can I purchase individual health coverage with a pre-existing medical condition? |
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You can. In some cases, individual insurers have to offer you coverage. In other cases, if they don't deny you coverage outright based on your medical history, they can deny coverage of a pre-existing condition for a certain period of time. DB101's program description of HIPAA and California Protections has a section addressing these issues. |
7) What is a pre-existing condition for individual coverage? |
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In some cases, insurance companies are not allowed to look at your medical history. If they are allowed to, they can look at your entire medical history to determine if they are going to cover you and how much your policy will cost. If they do decide to cover you, there are limits on what constitutes a pre-existing condition and how long they can exclude coverage for it. DB101's program description of HIPAA and California Protections has a section addressing these issues. |
8) What prescription drug coverage comes with individual health coverage? |
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| This depends on the individual plan selected. Some plans provide prescription coverage as a part of the health plan. In some situations prescription drug coverage will be a separate plan. There also may be limits on the prescription drug costs covered annually. Make sure that you thoroughly understand these provisions before purchasing your coverage. |
9) How much will individual health coverage cost? |
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This depends upon the health plan you are able to purchase. In most cases individual health coverage can be the most expensive way to access health coverage with a pre-existing medical condition. |
10) Does what I have in the bank and/or what I own, such as a home or car, affect my eligibility for individual health coverage? |
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No. Private individual health insurance policies are not governed by any state or federal laws that mandate or determine financial eligibility requirements. |
11) How soon after applying will I be eligible for benefits from an individual health coverage plan? |
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This depends upon conditions and terms of the policy you purchase. |
12) What other benefit programs are available to me and how do they work with individual health coverage? |
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Other private or public benefits plans may be available to you if you meet their specific eligibility requirements. Each benefit plan determines how it interacts with any other public or private coverage. |
13) How do I stay eligible in individual health coverage? How often do I have to reapply? |
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You should never have to reapply unless you let the policy lapse by failing to make premium payments. It is important to be aware that individual policy premium payments and coverage can change within legal limits. For example, your premiums, deductible or copayments can increase annually. It is also possible that the insurance company may decide to discontinue private health coverage for individuals in a specific county or state. In that case, you would have to apply to another company and meet its eligibility requirements. |
14) Are there special rules for immigrants related to individual health coverage? |
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An individual health coverage policy may cover an immigrant independent of their legal status depending on policy rules. |
15) Does changing jobs affect my eligibility for individual health coverage? |
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No, it does not. If you purchased individual health coverage, changing jobs should have no impact on your coverage as long as you keep current with premium payments. If employer-sponsored health coverage is being offered through a new job, any pre-existing condition exclusionary period may be reduced by the amount of time you had prior coverage. DB101's program description of HIPAA and California Protections has a section addressing these issues. |
16) Does California offer programs to access health coverage for individuals with a pre-existing condition? |
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Yes. There are a limited number of ways to access health coverage with a pre-existing condition. Some states have Major Risk Pool programs, health coverage programs for children, infants and mothers. In California the Governor appointed a board called the Managed Risk Medical Insurance Board (MRMIB) to administer three programs. For more information about MRMIB, go to http://www.mrmib.ca.gov . The three health care programs that MRMIB administer in California are: Access for Infants and Mothers (AIM) provides low cost health insurance coverage to uninsured, low income pregnant women and their infants; The Healthy Families Program (HFP) provides low cost health, dental and vision coverage to uninsured children in low income families; and, The Major Risk Medical Insurance Program (MRMIP) provides health insurance for Californians who are unable to obtain coverage in the individual health insurance market. |
17) What else should I know? |
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For individuals with pre-existing conditions, the easiest and most affordable way into private health coverage is through employer-sponsored policies. Depending on the specifics of the organization and the plan, health coverage through a union or professional organization may also be a good option. Whatever your circumstance, invest the time to research all available options. A thorough knowledge of all available types of coverage will help you to make the best decision. |
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