Quick Introductory Tips About California Health Insurance - Ratinah

California Health Insurance - It's important to look at carrier policies and restrictions regarding pre-existing conditions, waiting periods, and exclusions as they can vary from company to company. This is just an overview in layman's terms.

Quick Introductory Tips About California Health Insurance - Ratinah

First ... what is a pre-existing condition. The official definition reads as follows:

1. Pre-existing conditions

Any illness or health condition for which you received medical advice or treatment during the six months prior to obtaining health insurance. Group health care policies cover pre-existing conditions after you've been insured for six months, and individual policies cover pre-existing conditions after you've been insured for one year. Reference CIC Section 10198.7. Creditable coverage must be factored into the exclusion of pre-existing conditions in either the individual or group policy.

Basically, it's a medical condition, illness, or injury for which you have recently had treatment, are currently undergoing treatment, or have had treatment in the past. The context in which an insurance company will look at pre-existing conditions largely depends on the type of insurance.

2. California Individual and Family health insurance

This type of coverage is medically covered which means you must qualify on a health basis. Pre-existing conditions have the most impact here and affect coverage in two ways.

First, you must qualify for health-based coverage so the operator can increase your rates or refuse/suspend coverage altogether based on your pre-existing conditions. They usually have underwriting guidelines that define how they can look at a particular problem. Ultimately, the insurer (the person who decides to approve or deny the health coverage) makes the final decision based on the information found in the health application or medical records (if requested).

For some cases, health insurance carriers may want a certain amount of time from certain situations before offering coverage. The general rule is 6 months to a year for simpler situations (simple fracture, infection, etc). Some issues are considered uninsurable so they will never offer coverage.

If you are unable to qualify for individual-family health insurance in California, you can find options for the uninsured through the State such as MRMIP.

The second way that pre-existing conditions can affect coverage for California Individual Family health insurance is after approval. If approved for cover, there can be a waiting period for treatment (payment) of a pre-existing condition of up to 6 months if you have no previous coverage or coverage has expired for more than 62 days. Basically, they will consider time on the previous qualification plan (perhaps individual, small group, short term) towards a six month waiting period for pre-existing conditions.

3. Tier upgrade with Individual and Family coverage

If carriers don't refuse coverage based on pre-existing conditions, they can increase rates. Tier 1 is the best rate and you can find these rates when you quote individual California health insurance. Tier 2 is usually 25% higher than this standard rate. Tier 3 is usually 50% higher and Tier 4 is usually 100% higher. Some carriers apply different increments. For example, Blue Shield of California has a much higher Tier 5. These tier upgrades are unlocked and you may be able to remove them or lower them in the future after time has elapsed from certain situations (assuming you are in good health). We recommend submitting the required change of cover form every 3-4 months until this rate increase can be scaled up.

4. California Small group health insurance and pre-existing conditions

Pre-existing conditions are treated differently for Small Groups in several important respects. HMOs are usually not subject to a waiting period for pre-existing conditions. Maternity in California usually does not incur a waiting period for HMO or PPO plans. Otherwise, the six month waiting period is the same as the individual plan. Always file all claims through any carrier and let them decide on the waiting period.

Small Groups have no tiers but by law carriers can increase or decrease 10% of the standard rate (California Small Group Request for Quote at www.calhealth.net) based on the health of the group. This is called RAF (Risk Adjustment Factor). A 1.0 RAF is the standard fare. 1.1 will be 10% higher and .90 will be 10% lower. The larger your group, the more likely you will have a lower RAF. Some operators automatically give small groups an additional 10% because there are fewer people to spread the risk between them.

5. Exceptions from certain conditions

California law prevents carriers from excluding conditions that certain applicants may have (if benefits are covered) once approved as permitted by other states. This is a mixed blessing. On the one hand, new registrants do not have to worry about the condition occurring again and the coverage decreasing over a certain period of time. The downside is that one may not qualify for coverage at all which defeats the purpose of banning exceptions to begin with... The law of unintended consequences. Keep in mind that this exception only deals with a pre-existing condition of a specific person. Some plans will exclude certain coverages (i.e. maternity, brand-name drugs) by design. The plan summary and benefit description will list exceptions to the standard.

It's important to look at carrier policies and restrictions regarding pre-existing conditions, waiting periods, and exclusions as they can vary from company to company.

That's Quick Introductory Tips About California Health Insurance - Ratinah

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