Health Insurance Questions and Answers

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Individual and Family Coverage

These questions and answers apply to health insurance for individuals and families residing in most states, as they reflect general health insurance industry practices. But state laws and insurance practices vary, so these answers are not guarantees. They are simply the general observations of an experienced health insurance professional.

How long does it take to enroll in a health insurance plan?

If you are buying permanent health insurance, it depends on your health history and the insurance company to which you are applying. An application from a healthy young person may be approved in a day or two.

However, if you have health history problems, the insurance company underwriters are going to take a closer look, and their evaluation could take a couple weeks or more -- depending on the specifics of your health history.

If you need immediate health insurance, consider short-term or temporary coverage, You can obtain this type of protection within a day.

Do I have to take a physical exam to get health insurance coverage?

Probably not.  The health insurance companies represented by MedPlan Access rarely require physical exams. The occasional exceptions usually involve older applicants who have not recently consulted a physician.

Can my health insurance application be denied?

Yes. Whether your application is approved or denied primarily depends on your health history.

If you are concerned about how a health insurance company will view your medical record, get a professional assessment from a knowledgeable health insurance agent.

Can I pay less for health insurance if I bypass agents and deal directly with an insurance company?

No.  Health Insurance rates are strictly regulated by the state. Health insurance will cost the same whether you use an independent health insurance agent or deal directly with an insurance company.

Why should I use a health insurance agent or broker?

For no additional charge, a knowledgeable health insurance professional can provide advice and assistance at all stages of the health insurance purchasing process.

Must I pay a fee to an agent or broker?

No.  The health insurance agent or broker is paid a commission by the health insurance company. No additional fees are added to your health insurance rates.

Will an "individual" health insurance policy cover my pre-existing condition?

If you have 18 months of qualifying (under HIPAA) continuous prior health insurance coverage, the answer is yes -- assuming the insurer agrees to insure you. Even if you have qualifying continuous prior coverage, the insurance company can still decline to insure you based on your health status.

In addition, some insurance companies will waive the pre-existing condition exclusion for medical conditions disclosed on the application and not excluded by rider to the policy, but this is the exception rather than the rule.

What constitutes qualifying continuous prior coverage under HIPAA?

"HIPAA" is The Health Insurance Portability and Accountability Act of 1996, which defines the qualification as "creditable" health insurance for 12 months, with no lapse in coverage of 63 days or more. "Creditable" means most types of comprehensive major medical health insurance, but does not include short-term health plans.

Can I insure my children over age 18?

Health insurance plans will typically insure dependent children over age 18, as long as they are full-time students. This full-time student coverage can be maintained up to age 26.

How do insurance companies define "pre-existing condition?"

Each insurance company has its own definition. However, the following wording is consistent with most health insurance policy provisions: "A pre-existing condition is a medical condition that would cause a normally prudent person to seek treatment during the twelve months prior to the beginning of coverage."

How do age, gender, tobacco use and residency affect the price of health insurance?"

The older you are, the higher the price of individual health insurance.

For example, up to age 55, women are usually charged more than men. From age 55 to 65, health insurance tends to be more expensive for men.

Tobacco use typically adds 20% to 40% to the cost of health insurance. Coverage is usually more expensive in urban areas than in rural areas.  These pricing practices follow from statistical trends measured by health insurance companies.

I'm pregnant. Can I obtain health insurance?

No.  Unlike employer-sponsored group health plans, an "individual" health insurance company will not agree to insure you if you are pregnant or if you are an expectant parent.

Can I add dependents to my existing individual health insurance policy?

You can automatically add newborns, but adding other dependent family members is subject to underwriting evaluation.

What are my options if my health insurance application is denied?

You can try applying to another health insurance company.

Insurance companies use different guidelines. Lots of people who are rejected by one insurance company are able to obtain coverage from another insurance company.

It depends on the health conditions at issue. If you have been rejected for health insurance, seek advice from a knowledgeable agent.

If no health insurance company agrees to insure you, you may qualify for enrollment in your state's comprehensive "safety net" plan.

I am overweight. Does it make a difference in my health insurance rates?

Yes. Health insurers use their own height/weight tables in reviewing applications. If you have a "non-standard" height/weight, you may be charged higher rates or refused coverage.

Can a health insurance company terminate my "individual" coverage?

Just about every states provides provides strong consumer protection for this sort of thing. In general, the insurance company can terminate your coverage for only these reasons:

• Failure to make premium payment within the payment grace period
• Material omission or misrepresentation on your health insurance application
• The insurance company entirely withdraws from the individual health insurance business in your state.

How do I know if I can I keep my doctor under a new health insurance plan?

If you are considering a new health insurance, you should review the plan's physician and hospital network before submitting an application. This website contains links to PPO/HMO networks of the health insurance companies we represent.

For how long am I obligated to keep any health insurance I purchase?

You can terminate permanent health insurance whenever you want. Just inform the insurance company of your intentions.

However short-term health insurance is bought for specific durations, and there are no refunds if you want to terminate the plan before the end of the fixed coverage term.

What is short-term health insurance?

Short-term health insurance is designed to fill temporary gaps in your "permanent" health insurance coverage. These policies are relatively inexpensive and can go into effect very quickly. Most short-term plans last for no more than six months.

Should I get Health Savings Account (HSA)-compatible coverage?

Most people are better off with HSAs. For more information on this large subject, check out the HSA section of this website.

Are there meaningful differences in how insurance companies underwrite health insurance applications?

Yes. For example, one insurance company assigns "preferred" rates to a 5'10" male who weighs 215 lbs. Another insurance company assesses an additional 40% charge for the same person.

One insurance company charges an additional 40% for smokers. Another charges an extra 25%. One insurance company turns down a man with hypertension.  Another agrees to insure him.

A knowledgeable health insurance professional can help you identify a plan likely to provide an optimal outcome for you.

What is the difference between an HMO and a PPO?

HMOs restrict your non-emergency health care coverage to a limited network of physicians and hospitals. Alternatively, PPOs offer more provider choice, but provide lower benefits.

HMO enrollment is available through employer groups, but is extremely limited in the "individual market," where PPO plans are essentially the exclusive comprehensive health insurance option.

Will my health insurance rates increase because I get older?

Yes.  As people get older they tend to use more medical services, so health insurance companies accordingly adjust their premium requirements. For example, the health insurance rate charged to a 50-year-old is typically more than twice the health insurance rate charged to a 25-year-old.

Is there an important difference between Blue Cross and Blue Shield and other health insurance companies?

Blue Cross and Blue Shield health insurance companies are similar to other big health insurers such as UnitedHealthcare, Aetna and Humana, but they are also licensed to use the widely-recognized Blue Cross and Blue Shield brand name.

The Blue Cross and Blue Shield plans tend to be dominant vendors in the states where they do business. The brand name helps, but these insurance companies would not achieve enviable market positions if they were not delivering superior insurance products at competitive prices.