A Quick Introduction To California Health Insurance And Preexisting Conditions Waiting Periods And Exclusions

A Quick Introduction to​ California Health Insurance and Preexisting Conditions Waiting Periods and Exclusions


Its important to​ look at ​ a​ carriers policies and​ restrictions regarding preexisting conditions,​ waiting periods and​ exclusions as​ they can differ from company to​ company. ​
This is​ just an overview in​ laymans terms.
First...what is​ a​ preexisting condition. ​
The official definition reads as​ follows
Preexisting Condition
Any illness or​ health condition for which you​ have received medical advice or​ treatment during the​ six months prior to​ obtaining health insurance. ​
Group healthcare policies cover preexisting conditions after you​ have been insured for six months,​ and​ individual policies cover preexisting conditions after you​ have been insured for one year. ​
Reference CIC Section 10198.7. ​
Creditable coverage must be counted towards any preexisting condition exclusion in​ either an individual or​ group policy.
Essentially,​ it​ is​ a​ medical condition,​ illness,​ or​ injury for which you​ just had treatment,​ are undergoing treatment,​ or​ have had treatment in​ the​ past. ​
The context in​ which an insurance company will look at ​ preexisting conditions strongly depends on​ the​ type of​ insurance.
Individual and​ Family California health insurance.
This type of​ coverage is​ medically underwritten which means that you​ need to​ qualify based on​ health. ​
Preexisting conditions have the​ most impact here and​ it​ affects coverage in​ two ways.
First,​ you​ must qualify for coverage based on​ health so a​ carrier can increase your rates or​ decline/defer coverage altogether based on​ your preexisting conditions. ​
They typically have underwriting guidelines specifying how they may look at ​ particular issues. ​
Ultimately,​ the​ underwriter person who decides to​ approve or​ decline health coverage makes the​ final decision based on​ information found in​ the​ health application or​ medical records if ​ requested.
For some issues,​ the​ health insurance carrier may want a​ certain amount of​ time away from a​ give situation before offering coverage. ​
a​ general rule of​ thumb is​ 6 months to​ one year for a​ more simple situation simple broken bone,​ infection,​ etc. ​
Some issues are deemed uninsurable for which they will not offer coverage ever.
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 preexisting conditions can affect coverage for Individual Family California health insurance is​ after approval. ​
if ​ approved for coverage,​ there can be a​ waiting period for treatment payment of​ preexisting conditions of​ up to​ 6 months if ​ you​ did not have prior coverage or​ lapsed coverage for more than 62 days. ​
Essentially,​ they will take into account time on​ a​ prior qualified plan may be individual,​ small group,​ short term towards a​ six month waiting period for preexisting conditions.
Tier increase with Individual and​ Family coverage.
If a​ carrier does not decline coverage based on​ preexisting conditions,​ they can increase rates. ​
Tier 1 is​ the​ best rate and​ you​ can find this rate when you​ quote individual California health insurance. ​
Tier 2 is​ typically 25% higher than this standard rate. ​
Tier 3 is​ typically 50% higher and​ Tier 4 is​ typically 100% higher. ​
Some carriers apply different increases. ​
For example,​ Blue Shield of​ California has a​ Tier 5 which is​ much higher. ​
This tier increase is​ not locked in​ stone and​ you​ may be able to​ have it​ removed or​ lowered in​ the​ future once time has passed from a​ given situation assuming you​ are in​ otherwise,​ good health. ​
We recommend submitting the​ required change of​ coverage form every 34 months until this tier increase can be increased.
California Small group health insurance and​ Preexisting conditions.
Preexisting conditions are treated differently for Small Group in​ some important ways. ​
HMOs are typically not subject to​ waiting periods for preexisting conditions. ​
Maternity in​ California is​ typically not subject to​ waiting periods for either HMO or​ PPO plans. ​
Otherwise,​ the​ six month waiting period is​ the​ same as​ individual plans. ​
Always submit all claims through the​ carrier regardless and​ let them make the​ decision on​ waiting periods.
Small Groups do not have tiers but by law,​ a​ carrier can go up or​ down 10% from the​ standard Request Small Group California quote at ​ www.calhealth.net rate based on​ the​ health of​ the​ group. ​
This is​ called the​ RAF Risk Adjustment Factor. ​
a​ 1.0 RAF is​ the​ standard rate. ​
1.1 would be 10% higher and​ .90 would be 10% lower. ​
The larger your group,​ the​ more likely you​ will have a​ lower RAF. ​
Some carriers automatically give small groups the​ extra 10% increase as​ there are fewer people to​ spread the​ risk among.
Exclusions of​ certain conditions
California law prevents carriers from excluding conditions a​ specific applicant may have if ​ a​ covered benefit upon approval as​ other states allow. ​
This is​ a​ mixed blessing. ​
On one hand,​ a​ new enrollee does not need to​ worry about a​ condition reoccuring and​ having coverage declined during a​ period of​ time. ​
The downside is​ that a​ person might be unable to​ qualify for coverage altogether which defeats the​ purpose of​ banning exclusions to​ begin with...The law of​ unintended consequences. ​
Keep in​ mind that this exclusion is​ only dealing with a​ specific persons preexisting condition. ​
Some plans will exclude certain coverages i.e. ​
maternity,​ brand name ​Drug​s by design. ​
a​ plans summary and​ explanation of​ benefits will list their standard exclusions.
Its important to​ look at ​ a​ carriers policies and​ restrictions regarding preexisting conditions,​ waiting periods and​ exclusions as​ they can differ from company to​ company.
A Quick Introduction To California Health Insurance And Preexisting Conditions Waiting Periods And Exclusions A Quick Introduction To California Health Insurance And Preexisting
Conditions Waiting Periods And Exclusions Reviewed by Henda Yesti on January 06, 2018 Rating: 5

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