CALIFORNIA MEDICAL
Individual Family Guide

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Guide provided by
http://www.dmhc.ca.gov/  Link here

Individual California Medical Insurance

Individual medical insurance in California is insurance you buy on your own. Most insurance companies have on-line tools to help you find out how much California individual medical insurance will cost.  You can run an individual instant quote here.

If you have a chronic illness or other medical condition, it may be hard to buy individual medical insurance.

Underwriting

When you apply for California individual medical insurance, the medical plan uses a process called underwriting to look at your age, sex, and medical history to decide how much it will cost to provide your medical care. Plans must complete the underwriting process before they accept you and they must have an actuarial basis for decisions. An actuarial basis is a statistical reason.

Based on underwriting, a medical plan may refuse to insure you, or it may offer you different benefit packages and premium rates. You have a right to know why. A medical plan may also refuse to cover a pre-existing condition (an injury or illness that you had before you joined the plan) for up to 12 months.

Questions and Answers about Individual Insurance and Underwriting

What are My Rights?

A plan may refuse to insure you based on your medical history, but it may not deny you insurance:

  • Just because of your race, color, national origin, ancestry, religion, marital status, or sexual orientation.
  • Just because you have a physical or mental disability.
  • Just because you have a family history of breast cancer or genetic disease (and are not diagnosed with breast cancer or the genetic disease now).
  • Just because you are a victim of domestic violence.

A medical plan may not require an HIV test as a part of the application.

A medical plan may not do post claims underwriting. This means that a plan must research all reasonable questions about a person's medical history and information on an enrollment application before approving the application. If you complete the medical history on your California medical application fully and honestly and then are diagnosed with a medical condition after your insurance starts, a plan may not re-underwrite your insurance policy to include the increased risk (cost) of the new medical condition. A plan also may not rescind the insurance policy or limit your benefits. Rescind means to cancel all the way back to the effective date as if the insurance never existed.

What happens if I do not complete the enrollment application fully and honestly?

Medical plans use the medical history information on the enrollment application to decide if they will offer you insurance. Medical plans may request copies of your medical records to investigate any questions or discrepancies arising from the medical history answers you provided on your application. If you intentionally provided false information or if you intentionally left out important facts on the application, the medical plan may rescind your insurance coverage. This means that the medical plan can cancel your medical insurance all the way back to the day it began, as if it never existed. If this happens, the plan will not pay for the cost of medical care services you received. This may also make it hard for you to get insurance in the future.

When should I cancel my old medical insurance if I am applying for new insurance?

You should keep your current medical insurance until you are sure that your application was accepted and approved. Do not cancel your insurance until your new coverage starts. Please examine your options carefully before declining group coverage or continuation coverage, such as COBRA that may be available to you. You should be aware that companies offering California individual medical insurance typically require a review of your medical history that could result in a higher premium or you could be declined coverage entirely.

What if no medical plan will offer me individual insurance because of my medical history?

If you can not buy insurance because no insurance company will cover you, find out about MRMIP. MRMIP is California's insurance program for people who are not able to buy California individual medical insurance because of their medical history.

May a Medical Plan Cancel My Insurance?

A medical plan can cancel your insurance for the following reasons:

  1. You did not pay your premiums.
  2. You intentionally provided false information or intentionally left out important facts on your enrollment application. A plan may rescind your insurance coverage. For more information, see the question "What happens if I do not complete the enrollment application fully and honestly?"
  3. The plan is no longer offering individual insurance in California.

Do all medical plans have the same underwriting guidelines for offering insurance?

No, each medical plan has its own underwriting guidelines. Medical plans must file the following information with the DMHC:

  • medical conditions that would automatically not be approved;
  • medical conditions that may not be approved;
  • height and weight standards;
  • medical history, medical care service utilization, and lifestyle or behavior that may cause the plan to deny insurance or limit the products they offer.

Note - the DMHC may not disclose medical plan specific guidelines.

What medical conditions will cause a medical plan to automatically refuse or deny my application for insurance?

There are many medical conditions that may cause a medical plan to automatically deny or not approve your application. These may include the following:

  • medical problems for which you have not seen a doctor;
  • medical problems that a doctor can not explain;
  • medical problems for which you have not completed treatment.

A medical plan may also automatically deny your application for the medical conditions below. There may be other medical conditions that are not on this list.

  • AIDS
  • Cancer, under treatment
  • Cirrhosis
  • Current infertility treatment
  • Diabetes with complications
  • Heart disease
  • Hemochromatosis
  • Hepatitis
  • History of transplant
  • Lymphedema
  • Multiple Sclerosis
  • Muscular Dystrophy
  • Pregnancy, pregnancy of your spouse or significant other, planned surrogacy or adoption in process
  • Renal failure or Kidney Dialysis
  • Severe mental disorders, such as major depression, bipolar disorder, schizophrenia or psychopathic personalities
  • Sleep Apnea
  • Systemic Lupus Erythematous

What will cause a plan to offer me insurance at a higher premium rate or limit the products or benefit packages I can get?

Medical plans will offer you insurance at a higher premium and/or limit the benefit packages or products, like PPOs, if you had a medical problem in the past but you have recovered or you have been without symptoms for some time. Plans will also do this for minor medical problems that you had in the past or may currently have. Medical plans do this because there is a risk that it will cost more for your medical care than if you were completely healthy. Each California medical application and medical plan is different. A medical plan may charge a higher premium or limit the products they offer for the medical conditions below. There may be other medical conditions and time frames that are not on this list.

  • Allergies, while testing is in process
  • Breast Implants (non-silicone)
  • Ear infections, controlled with medications
  • Joint sprain or strain, recovered and no restrictions
  • Lyme's disease, without symptoms after one year
  • Migraine headache, mild and infrequent with no emergency room visits
  • Mild depression
  • Ringworm
  • Stroke, after 10 years with no reoccurring problems

Will a medical plan look at my height and weight when I apply for insurance?

Yes. Medical plans usually look at your height and weight when they decide to offer insurance. They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese. Some plans use a measurement called the Body Mass Index (BMI) to decide. If your BMI is higher than 39, a medical plan will usually not offer you insurance. If your BMI is 30-39, a medical plan may offer you insurance at a higher premium. If you have medical problems because of your weight, such as diabetes or heart disease, a medical plan may refuse to insure you, even if your BMI is under 30.

May a medical plan look at my smoking and drinking history when I apply for medical insurance?

Yes. Medical plans may look at smoking and drinking history when they decide to offer insurance.

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