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By Jacques Chambers
(click here to download pdf)
Insurance companies, being profit-making entities, are not really interested in providing health insurance to someone who has known health problems. While they are protecting their profits through medical underwriting of new applicants, they are also creating a barrier to coverage for someone, like a person with HCV, who desperately needs health insurance to help with medical bills.
Although state insurance departments put some restrictions on what insurance companies can use to exclude someone from coverage, generally insurance companies are free to ask about health history and current medical conditions. They also are allowed to decline coverage for any applicant who, they believe, poses a greater risk than “average,” and they frequently deny coverage to persons with even minor medical issues. They will not accept anyone with a history of HCV.
Primarily due to state and federal legislation that requires it, however, there are ways a person can obtain health insurance regardless of his or her medical condition or health history. This article discusses the various methods by which you can purchase health insurance on a “guarantee issue” basis, that is, without medical underwriting.
Employer Provided Health Insurance
Most people get their health insurance through their employer, but it was not always available to all employees. Now, under a federal law called HIPAA, if you work for an employer who provides health insurance to its employees, you cannot be refused the insurance because of your medical condition or health history. If the employer offers it and you are a full-time employee in a class that would be otherwise eligible for it, you must be allowed to enroll in the plan regardless of your health.
In some states, such as California, state law permits insurance companies to ask health questions of employees of a small group, under 50 employees for example, but the insurance companies can only use that information to adjust the group’s rates within a very limited band. The difficulty there is not in being turned down, but with disclosure – usually the enrollment forms go to the insurance company through the employer and many employees of small companies would rather not disclose their status. In such cases, it is usually better to work with the insurance company or agent directly to get the enrollment form submitted around the employer.
This right to health insurance is available not only to new hires, but also to persons who had originally declined the insurance and later changed their mind, although there may be some temporary limitations on coverage for these “late enrollees.”
There are advantages and disadvantages to getting health insurance through your employer. The primary advantage is that the employer pays most or all of the costs of the health insurance, and many employers offer a choice of plans so that each employee can choose the plan that best fits his/her needs.
The primary disadvantage is that your health insurance is tied to your employment. If the employer changes plans, you have no choice but to change plans too, even if it is means less coverage.
Another drawback used to be that you lost your insurance when your employment stopped. COBRA Continuation laws have helped some, but the extension of coverage is limited to between 18 and 36 months.
Now, thanks also to the HIPAA law, once you have acquired health insurance through an employer, you have the right to keep either that insurance or a private plan of similar quality, even if you terminate employment and after COBRA expires. That means that once you acquire health insurance through an employer you will be able to maintain some form of health insurance regardless of any changes in your employment status.
Eligible Spouse or Domestic Partner of an Employee with Health Insurance
If you are the spouse of an employee who gets health insurance through an employer, you too are eligible for health insurance just as the employee is. Also, more and more employers and health insurance plans allow domestic partners the same rights to health insurance as a married spouse.
Because there is no stan dard definition of a “domestic partner,” each health plan will have its own requirements as to who can be covered as a “domestic partner.” It usually includes the partner in a committed relationship regardless of gender. Some plans require that they live together; others don’t. A few plans will permit any other person to whom the employee has close ties, including a parent or sibling, to be included in the plan.
Union or Guild Health Plans
Most union employees are covered through employer provided health plans that are part of a bargaining agreement with the union. However, some unions and trade guilds provide health insurance directly to its members. This is most common in trades or occupations where the union member either works free-lance or moves frequently from employer to employer. Examples would include: musicians, actors, writers, editors, decorators, truck drivers, and some professional occupations such as attorneys, architects, and dentists.
The requirements for joining the union health plan, however, can be fairly strict. Those unions that permit any dues-paying union member to join the health insurance will have strict requirements as to who is eligible to join the union. Some will still require all enrollees to complete health questionnaires which may result in denial of coverage.
Some union plans are more liberal on membership but will require a minimum number of hours worked or dollars earned in that profession to be eligible for the health insurance plan.
You may want to ask your professional association about health insurance and whether “medical underwriting” is required to join the plan.
However, be wary of any “union” plans that purport to accept anyone and offer health insurance. Most such plans are uninsured and usually go bankrupt or are closed down by regulatory authorities.
Association Plans
At one time, many associations made health insurance available to their members without requiring medical underwriting. Unlike the union or guild plans which required some affiliation to join, most association plans were open to virtually anyone who was willing to pay the dues. This included groups like associations for independent sales representatives, self-employed individuals, and even some fraternal and social organizations.
However, as health insurance became more difficult to find and more expensive to maintain, insurance companies largely stopped writing association plans on such a loose basis. Those association plans that still exist virtually all require medical underwriting or other evidence of good health to join, just as if it were being purchased directly. Also many market themselves as broad health plans when they are really very restrictive in what and how much they cover.
Short Term Health Insurance
There is one health insurance product that is often included in lists such as this, but it provides no real help for anyone already diagnosed with a medical condition. These are the short term or “temporary” health insurance plans. They are written for a set period of time, usually from 30 days up to six months, and they cannot be renewed. While they rarely require answering any questions about your health, they are carefully worded so that they will never cover charges related to any condition for which you were already being treated when the coverage began. This makes them virtually worthless for our purposes.
Veterans Administration Medical Benefits
If you are a veteran of the military service you may be eligible for medical benefits from the Veteran’s Administration. For more information on getting benefits through the VA, go to http://www.va.gov/ and click on “Health – Benefits & Services.” While this may not affect many readers, for those who are, VA benefits can be very helpful especially for persons dealing with HCV.
Medicare/Medicaid
These federal health insurance plans can provide medical care to a person with HCV as well, assuming that you are eligible for the coverage.
Medicare is available to persons age 65 or older. It is also available to persons under age 65 who have collected Social Security Disability Insurance (SSD or SSDI) benefits for 24 months.
Medicaid (Medi-Cal in California and other names in other states, such as Tenncare) is a federally mandated health plan that is based on need. In addition to being either age 65 or older or disabled, you must show that your income and resources (assets) are low enough to qualify. Medicaid is administered by each state so the eligibility rules will vary slightly from state to state.
State High Risk Plans
Many states offer a health insurance plan for persons who, due to their medical history, are unable to purchase it on the open market. The plans vary from state to state. Most charge a premium that is higher than regular health plans, and some offer benefits that are not as broad.
To learn more about your state’s High Risk Health Insurance Plan, called by different names in each state, contact your state’s Department of Insurance.
Contact numbers and addresses for all 50 states’ Departments of Insurance can be found at http://www.ican2000.com/state.html.
In California, the plan is called California Major Risk Medical Insurance Plan (MRMIP). Information about the plan and a booklet of all the rules, plans, and rates can be obtained by calling 800-289-6574 or on the web at www.mrmib.ca.gov.
Open Enrollment Periods
A few states require their Blue Cross – Blue Shield plan to open their enrollment at least once a year to anyone who applies for health insurance, regardless of the applicant’s health history.
California is one of those states that does not currently require insurance companies to provide any open enrollment periods for individual applicants. While many believe otherwise, there are no insurance companies or HMOs, including Kaiser, which will accept individuals for coverage without medical underwriting.
Only New York lets people without insurance purchase it regardless of their medical condition at any time.
For more information on any such programs in your state, contact your state’s Department of Insurance at http://www.ican2000.com/state.html.
Confused about applying for disability? Click here
[Jacques Chambers, CLU, and his company, Chambers Benefits Consulting, have over 35 years of experience in health, life and disability insurance and Social Security disability benefits. For the past twelve years, he has been assisting people with their rights, problems, and other issues concerning benefits and disability. He can be reached at jacques@helpwithbenefits.com or through his website at: http://www.helpwithbenefits.com.]
Copyright, (October, 2005) Hepatitis C Support Project / HCV Advocate www.hcvadvocate.org. All Rights Reserved. Reprint is granted and encouraged with credit to the Hepatitis C Support Project
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