Note: None of this should be taken as legal or tax advice.
In a recent post, we provided a
state-by-state guide to guaranteed issue individual health insurance. While this guide may be helpful as a national overview, it does not provide state-specific information on th policies or application requirements. Since regulation of insurance is a state responsibility, the process for obtaining guaranteed issue health insurance varies from state to state. The purpose of this post is to provide a concise guide to purchasing guaranteed issue individual health insurance in California. If you have questions, please leave a comment.
In California, there are three different ways to obtain guaranteed issue individual health insurance (assuming you do not already qualify for Medicare, Medicaid or another program):
- HIPAA Plans (All individual market carriers are required to offer these plans to eligible individuals)
- Conversion Policies (An individuals previous group insurance carrier is required offer these plans to eligible individuals)
- MRMIP (The state offers these "state risk pool" plans to eligible individuals)
HIPAA Plans California's
HIPAA program is different from many states because the state risk pool (MRMIP) is not the insurer of last resort for HIPAA eligibles. California meets its HIPAA requirement using the "Federal Fall-back" method. Under this HIPAA approach, all individual market carriers in California are required to offer a HIPAA policy to eligible individuals. If you qualify for a HIPAA plan, you cannot be denied insurance because of pre-existing conditions. For applicable rates and policy options, see the
Department of Managed Health Care website.
Conversion Policies
In California, an employee may also be eligible to purchase a guaranteed issue individual "conversion" policy if they lose their group health insurance. This is called a conversion plan because the employee converts from the group policy to an individual policy. When an employee's group plan ends, the group carrier must offer eligibile employees (employees with 3 months creditable coverage) an individual "conversion" policy. If you qualify for a conversion plan, you cannot be denied insurance because of pre-existing conditions. For applicable rates and policy options, see the
Department of Managed Health Care website.
MRMIP MRMIP (Major Risk Medical Insurance Program) is California's state risk pool for people with health problems who are not able to buy individual health insurance and are not eligible for the above HIPAA or Conversion plans. Californians qualifying for the program participate in the cost of their coverage by paying premiums. The State of California supplements those premiums to cover the cost of care in MRMIP. Because of funding limitations, MRMIP does sometimes have a wait list. For applicable rates and policy options, see the
MRMIP website.
Note: None of this should be taken as legal or tax advice. In my
previous post, I wrote about the 1996 HIPAA legislation and its requirement that states offer guaranteed-issue health insurance to all of its HIPAA-eligible residents. I also mentioned that 40 states go far and above what HIPAA mandates. These states offer forms of guaranteed issue individual health insurance (e.g. risk pools) to their medically uninsurable residents, regardless of the HIPAA requirements.
Health insurance sold on a guaranteed issue basis cannot reject applicants based on health or risk status. In a few states (e.g. New Jersey) all individual market insurers must guarantee issue all individual plans. In others states guaranteed issue requirements are much less restrictive.
If you have questions, please comment.
| State |
> HIPAA? |
Risk Pool |
Notes |
| Alabama |
No |
AHIP |
|
| Alaska |
Yes |
ACHIA |
|
| Arizona |
No |
N/A |
|
| Arkansas |
Yes |
CHIP |
|
| California |
Yes |
MRMIP |
|
| Colorado |
Yes |
CoverColorado |
|
| Connecticut |
Yes |
HRACT |
|
| Delaware |
No |
N/A |
|
| D.C. |
No |
N/A |
|
| Florida |
Yes |
N/A |
Eligible individuals, who are uninsured for 6 months, can buy a guaranteed issue limited benefit policy through the Cover Florida Health Care Program |
| Georgia |
No |
N/A |
|
| Hawaii |
No |
N/A |
|
| Idaho |
Yes |
N/A |
Individual market insurers must guarantee issue standardized policies to the medically uninsurable. These policies are called High Risk Pool Policies. |
| Illinois |
Yes |
ICHIP |
|
| Indiana |
Yes |
ICHIA
|
|
| Iowa |
Yes |
HIPIOWA |
|
| Kansas |
Yes |
KHIA |
|
| Kentucky |
Yes |
Kentucky Access |
|
| Louisiana |
Yes |
LHP |
|
| Maine |
Yes |
N/A |
All Insurers must Guaranteed Issue all products |
| Maryland |
Yes |
MHIP |
|
| Massachusetts |
Yes |
N/A |
All Insurers must Guaranteed Issue all products |
| Michigan |
Yes |
N/A |
BCBS of Michigan is Insurer of last resort |
| Minnesota |
Yes |
MCHA |
|
| Mississippi |
Yes |
MCHIRPA |
|
| Missouri |
Yes |
MHIP |
|
| Montana |
Yes |
MCHA |
|
| Nebraska |
Yes |
NECHIP |
|
| Nevada |
No |
N/A |
|
| New Hampshire |
Yes |
NHHP |
|
| New Jersey |
Yes |
N/A |
All Insurers must Guaranteed Issue all products |
| New Mexico |
Yes |
NMMIP |
|
| New York |
Yes |
N/A |
All Insurers must Guaranteed Issue all products |
| North Carolina |
Yes |
Inclusive Health |
|
| North Dakota |
Yes |
CHAND |
|
| Ohio |
Yes |
N/A |
Individual Market Insurers must guarantee issue standardized policies on a periodic basis. |
| Oklahoma |
Yes |
OKHRP |
|
| Oregon |
Yes |
OMIP |
Individual Market Insurers must guaranteed issue portability policies to individuals with 6 months creditable coverage |
| Pennsylvania |
No |
N/A |
|
| Rhode Island |
Yes |
N/A |
Individual market insurers must guarantee issue all products with 12 months of creditable coverage, provided that the applicant is not eligible for alternative group coverage, Medicare or any other state insurance plan |
| South Carolina |
Yes |
SCHIP |
|
| South Dakota |
Yes |
SDRP |
|
| Tennessee |
Yes |
AccessTN |
|
| Texas |
Yes |
TXHIP |
|
| Utah |
Yes |
HIPUtah |
|
| Vermont |
Yes |
N/A |
All Insurers must Guaranteed Issue all products |
| Virginia |
No |
N/A |
|
| Washington |
Yes |
WSHIP |
|
| West Virginia |
Yes |
AccessWV |
|
| Wisconsin |
Yes |
HIRSP |
|
| Wyoming |
Yes |
WHIP
|
|
SRC: State Health Facts Website
Note: None of this should be taken as legal or tax advice.
This post is about possibly the greatest secret of the 1996 HIPAA legislation, and maybe even individual health insurance. That is, federally mandated guaranteed-issue individual health insurance in all 50 states.
The federal law passed in 1996 (HIPAA) requires all states (beginning in 2006) to offer state-guaranteed individual health policies to individuals who meet certain eligibility criteria. Individuals who meet this criteria are commonly referred to as "HIPAA-eligible" (or "Federally-eligible") individuals. Forty (40) states go far beyond this federal mandate and offer state-guaranteed personal health policies to all of their residents (we will save this discussion for later post). This focuses entirely on an individual's eligibility requirements for federally mandated guaranteed-issue individual health insurance in all states.
Background:
Individual health insurance is less expensive for healthy employees in most states because individual carriers in those states are able to underwrite individuals based on their health condition. Subsequently, only 83% (nationally) of applicants medically qualify for personal health policies. The 17% who may not qualify based on underwriting may qualify for individual insurance (regardless of health conditions) as a HIPAA-eligible individual. This is all thanks to the Clinton Administration's passing of the 1996 HIPAA legislation.
Nestled deep inside the 100+ pages of 1996 HIPAA legislation are two sections (Section 2741 and 2744) that require states to make available individual health insurance to all HIPAA-eligible residents on a guaranteed issue basis (i.e. no denial of coverage).
Ok, so who qualifies?
People are HIPAA-eligible and are guaranteed the right to purchase individual insurance coverage if they meet the following criteria:
- they have had at least 18 months of previous health insurance coverage without a break in coverage lasting 63 days or more;
- their most recent period of coverage was under an employer-sponsored group plan, a church plan, or a government plan;
- they did not lose insurance coverage due to fraud or failure to pay premiums;
- they are ineligible for or have exhausted their COBRA or similar state, or federal continuation coverage; and
- they are not eligible for Medicaid, Medicare, or any other employer-sponsored plan.
Some Examples of "HIPAA-eligible" Individuals
1. An employee for a 15-person company loses his job. Because the company has less than twenty (20) employees, his employer does not provide COBRA. Because he has 18 months prior creditable coverage and is not eligible for Medicaid or Medicare, he is HIPAA-eligible.
2. A 100-person company drops their group plan. All employees who have 18 months prior coverage (without a lapse of greater than 63 days) become HIPAA-eligible, assuming they are not eligible for another insurance plan (e.g. Medicaid, Medicare, or any other employer-sponsored plan).
Want more information?
I recommend reviewing the following for solid background on HIPAA and its HIPAA-eligibility requirements:
