Individual Health Insurance
Individual health insurance is insurance you buy on your own. Most insurance companies have on-line tools to help you find out how much individual health insurance will cost.
If you have a chronic illness or other health condition, it may be hard to buy individual health insurance.
Underwriting
When you apply for individual health insurance, the health plan uses a process called underwriting to look at your age, sex, and health history to decide how much it will cost to provide your health care. Plans must complete the underwriting process before they accept you and they must have an actuarial basis for decisions. An actuarial basis is a statistical reason.
Based on underwriting, a health plan may refuse to insure you, or it may offer you different benefit packages and premium rates. You have a right to know why. A health plan may also refuse to cover a pre-existing condition (an injury or illness that you had before you joined the plan) for up to 12 months.
Questions and Answers about Individual Insurance and Underwriting
- What are my rights?
- What happens if I do not complete the enrollment application fully and honestly?
- When should I cancel my old health insurance if I am applying for new insurance?
- What if no health plan will offer me individual insurance because of my health history?
- May a health plan cancel my insurance?
- Do all health plans have the same underwriting guidelines for offering insurance?
- What health conditions will cause a health plan to automatically deny or refuse my application for insurance?
- What will cause a plan to offer me insurance at a higher premium rate or limit the products or benefit package I can get?
- Will a health plan look at my height and weight when deciding to offer me insurance?
- May a health plan look at my smoking and drinking history when I apply for insurance?
- Can I change from one individual plan contract to a different individual plan contract without underwriting?
What are My Rights?
A plan may refuse to insure you based on your health history, but it may not deny you insurance:
- Just because of your race, color, national origin, ancestry, religion, marital status, or sexual orientation.
- Just because you have a physical or mental disability.
- Just because you have a family history of breast cancer or genetic disease (and are not diagnosed with breast cancer or the genetic disease now).
- Just because you are a victim of domestic violence.
A health plan may not require an HIV test as a part of the application.
A health plan may not do post claims underwriting. This means that a plan must research all reasonable questions about a person's health history and information on an enrollment application before approving the application. If you complete the medical history on your application fully and honestly and then are diagnosed with a health condition after your insurance starts, a plan may not re-underwrite your insurance policy to include the increased risk (cost) of the new health condition. A plan also may not rescind the insurance policy or limit your benefits. Rescind means to cancel all the way back to the effective date as if the insurance never existed.
What happens if I do not complete the enrollment application fully and honestly?
Health plans use the health history information on the enrollment application to decide if they will offer you insurance. Health plans may request copies of your medical records to investigate any questions or discrepancies arising from the health history answers you provided on your application. If you intentionally provided false information or if you intentionally left out important facts on the application, the health plan may rescind your insurance coverage. This means that the health plan can cancel your health insurance all the way back to the day it began, as if it never existed. If this happens, the plan will not pay for the cost of health care services you received. This may also make it hard for you to get insurance in the future.
When should I cancel my old health insurance if I am applying for new insurance?
You should keep your current health insurance until you are sure that your application was accepted and approved. Do not cancel your insurance until your new coverage starts. Please examine your options carefully before declining group coverage or continuation coverage, such as COBRA that may be available to you. You should be aware that companies offering individual health insurance typically require a review of your medical history that could result in a higher premium or you could be declined coverage entirely.
What if no health plan will offer me individual insurance because of my health history?
If you can not buy insurance because no insurance company will cover you, find out about MRMIP. MRMIP is California's insurance program for people who are not able to buy individual health insurance because of their health history.
May a Health Plan Cancel My Insurance?
A health plan can cancel your insurance for the following reasons:
- You did not pay your premiums.
- You intentionally provided false information or intentionally left out important facts on your enrollment application. A plan may rescind your insurance coverage. For more information, see the question "What happens if I do not complete the enrollment application fully and honestly?"
- The plan is no longer offering individual insurance in California.
Do all health plans have the same underwriting guidelines for offering insurance?
No, each health plan has its own underwriting guidelines. Health plans must file the following information with the DMHC:
- health conditions that would automatically not be approved;
- health conditions that may not be approved;
- height and weight standards;
- health history, health care service utilization, and lifestyle or behavior that may cause the plan to deny insurance or limit the products they offer.
Note - the DMHC may not disclose health plan specific guidelines.
What health conditions will cause a health plan to automatically refuse or deny my application for insurance?
There are many medical conditions that may cause a health plan to automatically deny or not approve your application. These may include the following:
- health problems for which you have not seen a doctor;
- health problems that a doctor can not explain;
- health problems for which you have not completed treatment.
A health plan may also automatically deny your application for the health conditions below. There may be other health conditions that are not on this list.
- AIDS
- Cancer, under treatment
- Cirrhosis
- Current infertility treatment
- Diabetes with complications
- Heart disease
- Hemochromatosis
- Hepatitis
- History of transplant
- Lymphedema
- Multiple Sclerosis
- Muscular Dystrophy
- Pregnancy, pregnancy of your spouse or significant other, planned surrogacy or adoption in process
- Renal failure or Kidney Dialysis
- Severe mental disorders, such as major depression, bipolar disorder, schizophrenia or psychopathic personalities
- Sleep Apnea
- Systemic Lupus Erythematous
What will cause a plan to offer me insurance at a higher premium rate or limit the products or benefit packages I can get?
Health plans will offer you insurance at a higher premium and/or limit the benefit packages or products, like PPOs, if you had a health problem in the past but you have recovered or you have been without symptoms for some time. Plans will also do this for minor health problems that you had in the past or may currently have. Health plans do this because there is a risk that it will cost more for your health care than if you were completely healthy. Each application and health plan is different. A health plan may charge a higher premium or limit the products they offer for the health conditions below. There may be other health conditions and time frames that are not on this list.
- Allergies, while testing is in process
- Breast Implants (non-silicone)
- Ear infections, controlled with medications
- Joint sprain or strain, recovered and no restrictions
- Lyme's disease, without symptoms after one year
- Migraine headache, mild and infrequent with no emergency room visits
- Mild depression
- Ringworm
- Stroke, after 10 years with no reoccurring problems
Will a health plan look at my height and weight when I apply for insurance?
Yes. Health plans usually look at your height and weight when they decide to offer insurance. They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese. Some plans use a measurement called the Body Mass Index (BMI) to decide. If your BMI is higher than 39, a health plan will usually not offer you insurance. If your BMI is 30-39, a health plan may offer you insurance at a higher premium. If you have health problems because of your weight, such as diabetes or heart disease, a health plan may refuse to insure you, even if your BMI is under 30. You can find out your BMI with an online BMI calculator.
May a health plan look at my smoking and drinking history when I apply for insurance?
Yes. Health plans may look at smoking and drinking history when they decide to offer insurance.
Can I change from one individual plan contract to a different individual plan contract without underwriting?
People covered under an individual plan contract (or benefit package) for at least 18 months have the right to transfer to a different individual plan contract with the same health plan. You have the following rights if your individual plan contract started, or was renewed, on or after January 1, 2007:
- To transfer to any other individual plan contract offered by the same health plan with equal or lesser benefits. For example, you may be able to transfer from a plan contract with a $250 deductible to a plan contract with a $500 deductible with a lower premium, if offered by the plan.
- To transfer without the plan looking at your medical history or performing medical underwriting.
- To transfer at least once per year.
- To be sent a notice from the plan about your right to transfer whenever the plan changes the premium. This notice must tell you how you can get information from the plan about contracts available to you. This notice must also tell you that you may not be able to return to your current contract after a transfer.
Each plan must establish a ranking of its individual plan contracts. This will allow members to identify which individual plan contracts have equal or lesser benefits than the current contract. The plan must post the ranking on its website or send it to members when requested. Each plan must update its ranking whenever the DMHC approves a new individual plan contract or benefit design. The DMHC will not review the ranking of individual plan contracts established by a plan.
The right to change individual plan contracts DOES NOT apply to:
- Members enrolled in HIPAA guaranteed-issue individual plan products .
- Members enrolled in conversion coverage .
- Members enrolled in a specialized plan contract (for example dental plan, vision plan, etc.) .
- Members enrolled in Medi-Cal .
- Members enrolled in the Access for Infants and Mothers Program (AIM) .
- Members enrolled in the Healthy Families Program .