Am I eligible for health insurance?
August 9, 2012 6:02 PM   Subscribe

Do you guys think I will be approved or denied health insurance based on the following factors?

I have had consistent health insurance from my career over the last ten years. Although I've had different plans, the company has always been the same - CareFirst.
I am unemployed as of the end of this month (about time!) and want to get health insurance on my own. I found a good plan with CareFirst and applied on their website for instant approval but was given the notice that my application required further review due to some of the answers I gave. I'm pretty sure I know the reasons:

-I answered that I have high cholesterol and undergoing treatment of "proper diet and exercise."

-I answered that in the last five years I was diagnosed with heartburn and take prescription medication as needed.

-Only other thing I listed was a trip to a podiatrist to have a callous looked at because I was wearing tight shoes at the time (very minor, I know).

Other than that, I'm in shape and healthy. CareFirst obviously has access to my health records because I've been with them for so long.

Based on what I've written above, does anyone see a reason why I'll be denied? I'm concerned now because I've read so many horror stories of healthy people being denied coverage for very minor or even no apparent reason.

I know we can only speculate, but does anyone have any experience or words of wisdom based on my situation? The wait is going to kill me because I thought health insurance would be a simple quote-review-purchase thing online. Thanks!
posted by Yunani to Health & Fitness (16 answers total)
Assuming this is the US, one of the provisions of the ACA (aka Obamacare) is that you can no longer be denied health insurance for pre-existing conditions.
posted by zombieflanders at 6:10 PM on August 9, 2012 [1 favorite]

Response by poster: Thanks for the reply. I forgot about the pre-existing conditions clause of the ACA. Important to note though that I believe that doesn't fully take effect for adults until 2014.
posted by Yunani at 6:27 PM on August 9, 2012

one of the provisions of the ACA (aka Obamacare) is that you can no longer be denied health insurance for pre-existing conditions.

That's true, but that provision doesn't take effect in 2014.

I don't know that any of us can reasonably predict how CareFirst's underwriting will work, but if you are denied coverage, you have a few different options for obtaining coverage in the meantime.

If your former employer has more than 20 employees, and your unemployment is for any reason other than being fired for serious misconduct, you can continue your coverage under your old group plan for your employer for 18 months through COBRA, which would take you up through 2014 when the ACA's pre-existing condition protection kicks in. You would have to pay the portions of your premium that your employer previously did, but actually even if CareFirst or another insurer will write you an individual plan, this could still work out cheaper than the rate they quote you, and it's worth your time to at least figure out what the price difference is. You would be eligible for COBRA even if you resigned voluntarily.

Your other option, which would only be viable if you were denied coverage, would be to wait out six months of being uninsured and then apply for coverage through your state or federal Pre-Existing Condition Insurance Plan. Six months of no insurance coverage is a pretty serious financial risk if you have substantial assets that could be at risk if you have some catastrophic medical issue in the meantime, but makes a lot of sense if you're poor enough that you don't have much to lose anyway. The caveat here is that those eligibility rules are true in states that use the Federal PCIP plan - I think states that run their own plans have some latitude to change the eligibility rules on their plans.
posted by strangely stunted trees at 6:34 PM on August 9, 2012 [1 favorite]

It is my understanding that health insurance companies, no matter how long your relationship with them, will do whatever they can to deny you coverage. The blood pressure stuff alone....

Good news, let's get Obama elected again. ACA, though not perfect, would take care of this.
posted by Kronur at 6:36 PM on August 9, 2012 [2 favorites]

Since you have been continually covered for the last 10 years, you can't be denied. I'm pretty sure that rule existed pre-Obama care. However, that doesn't mean that you can find an affordable plan. I checked into individual plans for myself just for research (I have excellent coverage from my employer). I am a cancer survivor with a high BMI, but no other chronic conditions. The cheapest individual plan (with any degree of decent coverage) was about $1250 a month.
posted by kimdog at 6:38 PM on August 9, 2012 [1 favorite]

To clarify, my understanding is that you can only be denied coverage if you allow your existing insurance to lapse.
posted by kimdog at 6:40 PM on August 9, 2012

RE: Pre-existing conditions and ACA

True, they don't go into effect for all Americans until 1/1/14, but according to CareFirst, they do have Pre-Existing Condition Insurance Plan (PCIP) plans in states that support them. You can see if you live in one of them (and what exactly a PCIP is) here.
posted by zombieflanders at 6:48 PM on August 9, 2012

Response by poster: Thanks for the replies so far; I'm learning a lot.

The quote for the policy I applied for is $100 per month. I hope they don't raise the quote on me.

My company has fewer than 20 employees so I don't think COBRA will be an option for me. My coverage is good through the end of the month so I hope carefirst makes a decision SOON!!
posted by Yunani at 6:51 PM on August 9, 2012

Letting insurance lapse, as kimdog mentions, takes 30 days of total inactivity by you. Document everything including your efforts to get new coverage. You should get a written statement from Carefirst which describes your status as being continuously covered since [date]. This is called something like a statement of continuous coverage (duh). Your efforts to sign up for new care, even if stymied somewhat by whatever, indicate that you intended and intend to remain covered at all times, but even prior to ACA, by not lapsing, there's no "pre-existing" in your medical condition to be used against you.

I'm not sure how ACA affects this; now that insurance companies are forced to take on the high-risk group, they might group you as high risk since the above system doesn't really apply, I think (IANAL) and so there's no incentive for them to treat your case as anything other than what it is, medical risk-wise. This is the part where the Affordable part of the ACA can go out the window. This could get seriously expensive unless there's some price-controlling aspect going on, which for all I know there is.

I can't imagine it's still around, but for a while there, the Stimulus money was subsidizing COBRA to the tune of 65%. Worth checking. Good luck.
posted by Sunburnt at 6:53 PM on August 9, 2012

Response by poster: Sunburnt, thanks for the information. Carefirst should hopefully have all my records and know my coverage history. That's part of the reason I'm trying to get insurance with them - I've already used them for so long.

Kind of funny that we're talking about me being high risk when I don't go to the doc often, work out all the time, eat cleanly and am in great shape. I guess heartburn and high cholesterol (genetic) really make the difference in a not so good way! My doc isn't concerned about either of those. He just says " you're in great shape, keep eating well and working out and you'll be fine."
posted by Yunani at 7:01 PM on August 9, 2012

My company has fewer than 20 employees so I don't think COBRA will be an option for me.

Can you ask your employer about this? They may be able to offer you COBRA and may be willing to do that even if they aren't required to.
posted by alms at 7:56 PM on August 9, 2012

My suspicion is they are merely doing their due diligence in part because you went to them instead of them going to you. I would not worry at this point. Basically, if you want health insurance, the company wants to make sure they aren't being taken to the cleaners. They are less suspicious if they have to talk you into it, if that makes sense.
posted by Michele in California at 9:23 PM on August 9, 2012

Your profile doesn't say what state you're in - in Michigan there's a state law that allows for continuing policies even if your previous company had fewer than 20 people. We're in the midst of a similar insurance move and found that if we stayed with the same carrier there was no break in coverage for pre-existing conditions and if we changed carriers there would be a 120 day lack of coverage for them. I don't know if that is due to a state or federal law though.
posted by leslies at 5:06 AM on August 10, 2012

Response by poster: Hey everyone, sorry for the long copy/paste, but I found the paragraph below to be useful for my situation:

"If you are in between jobs and previously had employer-based health insurance, it is critical that you avoid a prolonged lapse in medical coverage. Health insurance companies try to control costs by invoking "pre-existing condition" clauses, refusing to cover treatments for a medical condition they say you had before you purchased the health insurance policy. The Health Insurance Portability and Accountability Act, HIPAA, protects you from having conditions that were covered by your current health insurance plan being ruled “pre-existing” when you move form one job, and therefore one health insurance plan to another. However, the HIPAA protections only apply if there has not been a significant lapse in coverage. Under the law, you only have about two months for protection under HIPAA before a future health insurer can turn you down for a new policy based on a pre-existing condition. Under the federal HIPAA regulations if you have had health insurance for more than 18 months an insurance company cannot place a waiting period on pre-existing medical conditions if you haven’t been without medical coverage for over 63 days.

While you can maintain your health insurance under the COBRA provisions, COBRA is generally an expensive option. Most high-deductible health insurance plans, which have lower relative monthly premium costs, will meet the HIPAA requirements for “continuous coverage”. Some short-term health insurance policies may also keep you HIPAA eligible, but it is the exception rather than the rule for short-term plans because of their limited scope of coverage. It is best to check with a qualified health insurance professional before you assume that a short-term health insurance policy qualifies as “continuous coverage” under HIPAA.
Finally, keep in mind that HIPAA was designed to make the transition from health insurance plans from your new employer when switching jobs easier, and to avoid new waiting periods for pre-existing condition exclusions. The law does not guarantee that you will receive the same level of benefits, claim limits, etc. that you had with your previous health insurance plan."
posted by Yunani at 5:56 AM on August 10, 2012

I can't imagine it's still around, but for a while there, the Stimulus money was subsidizing COBRA to the tune of 65%. Worth checking.

That ended sometime in 2010. I remember because I became unemployed in late June 2010 and seem to recall that I'd just missed the deadline.

Luckily I was only briefly unemployed so I was able to do COBRA, but I did look into getting private insurance in case it turned into a long term thing and I was told that I would not be denied private insurance but they would likely add a proviso (can't remember the proper term; rider perhaps?) against covering anything related to my pre-existing condition. I have psoriatic arthritis and the medication that I take for it is prohibitively expensive. My friend has a thyroid condition (hypo or hyper) and had a breast cancer screening scare, which required a second mammogram. She too was questioned regarding these "red flags", but ultimately was able to get private health insurance.
posted by kaybdc at 6:48 AM on August 10, 2012

Response by poster: kaybdc, thanks for the reply and information. My impression from the paragraph I posted above is that those provisions for pre-existing conditions cannot be inserted in a policy if you meet the eligibility under HIPAA (had 18 months of insurance, no significant lapse, etc).

I'll report back when I receive a decision from CareFirst.
posted by Yunani at 6:59 AM on August 10, 2012

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