California health
insurance
Individual and Family health
Insurable for health coverage
Qualifying for Individual
California Health Coverage
Individual and Family medical
insurance is different from
Group (Company) insurance in
that they can decline and or
change rates based on your
medical at the time of
application. Below we have
some common reasons for
difficulties in getting approved
but first a few quick tips
regarding qualifying for
coverage.
Some health issues and reasons
for declination are time
sensitive. This means that we
may be able to qualify at a
later time with more time from
when a health issue is sign,
symptom, and treatment free.
For very basic situations, we
generally need 3-6 months away.
More involved situations might
require 12-18 months and serious
issues such as certain kinds of
cancer can require years away.
There are
multiple carriers on the
California health market and
although their underwriting
guidelines are similar, they do
fluctuate. This means that we
may get a declination from one
carrier and an approval from
another. Based on experience (2
decades now), it appears that if
claims spike, underwriting
tightens so there can be
applicants where we expect a
decline but get an approval and
vice versa. For questionable
health situations, it makes
sense to apply to two carriers
at the same time since you have
a 10 day free look window when
they come back with a decision.
This makes sense when time is
critical (such as being in the
Cobra election period).
Let's look
at medication costs which can
definitely affect our ability to
qualify for coverage. First, a
newer prescription can be more
concerning. If you have been on
a prescription for a longer
period of time (let's say 6+
months), the carriers can then
evaluate your application based
on monthly cost. This is how
carriers will look at
maintenance medications (for
example, cholesterol or blood
pressure). What is the monthly
cost? Brand name medications
obviously affect this analysis
quite a bit since they are much
more expensive. A generic
equivalent will weigh less heavy
on the underwriting decision.
Keep in mind that a sudden
switch to generic (or plan to)
will not help us qualify since
it falls under the "newer
prescription" issue above.
A Cobra
option can affect what we want
to do regardless of
underwriting. Cobra is
generally very expensive but
it's guaranteed issue
(regardless of health). We just
want to make sure we don't lapse
our Cobra election option or
monthly payment while applying
for individual health
insurance. We have written an
entire article on the Cobra
versus Individual California
health insurance option.
California
health carriers can offer split
decisions. They may approve one
family member and decline
another. There's an "all or
none" question on the
application which we recommend
not checking. It's best to let
the carriers underwrite
individually for family members
and see what they come back
with.
Carriers
are generally looking at recent
or more serious health history
situations. We all have health
issues and yet 80% of
applications get approved so
it's best to apply and see what
the come back with. Children
will be guaranteed issue now
anyway.
If you have
not had coverage for the last 6
months, you may be eligible for
the PCIP plan. We still need a
declination to qualify so we
want to apply for standard
coverage (ideally our preferred
plan) either way.
If you have
questions about your preexisting
conditions whether listed above
or not, please call us at
800/320-6269 or
email us to receive personal
assistance from a
licensed California medical
agent. We will be able to
advise you based on your
specific medical history.
More information on Enrolling
and qualifying for
Individual and Family California
medical insurance:
Pre-existing conditions
Guaranteed issue coverage for
children
What if you're declined
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