Individual and Family health
insurance is different from Group
(Company) insurance in that they can decline and or
change rates based on your health 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.
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Some
situations require time away from the condition in
order to qualify. For simple situations, a 6 month
period sign, symptom, and treatment free is a good
estimate. This can also pertain to
medication.
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It is
not uncommon to be declined by one carrier and
accepted by another even though the carriers have
very similar underwriting requirements.
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If we
are declined by a carrier, we may lose our Short
Term option. If there is an issue, and you have no
coverage, we recommend getting
Short Term coverage
first and then apply for the permanent plan.
-
Brand name medication
are heavily scrutinized these days due to the cost
associated with their use.
- If you are
currently on
Cobra, it
typically makes sense to apply for coverage as there
is no down side. You can remain on your Cobra if
the coverage is not approved. Cobra is usually
quite expensive.
- The carriers can
offer a split approval where one member is not
approved but the rest of the family is.
- The carriers are
mainly looking at current/recent and ongoing
situations. We all have a medical history but
situations that are stable, from which time has
passed, typically do not cause problems.
- If you are
exhausting or losing Cobra (continuation of group
coverage) you may be eligible for
HIPAA.
Please
check
with us if this sounds applicable.
Some common
reasons for declination/deferrals of coverage
-
currently
pregnant
or an expecting father
-
multiple
medications
especially brand name
-
recent (last 6 months including physical
therapy) injury
-
recent (last 2-3 years) treatment for heart
disease, diabetes, cancer, immune system
disorders, or any other serious medical
condition
-
height/weight outside guideline range
-
multiple conditions/injuries/illnesses
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 health
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 health insurance:
Enrolling in a Individual Family Health Plan
1.
What
is needed to start the process
2.
How long does it take
3.
Do I submit payment with the
application
4.
Is there a fee to apply
5.
Do I need a physical
6.
How can I expedite this
7.
Am I locked in for a period of
time
8.
How is payment handled
9.
Can I change my plan later
10.
Why
should I go with you
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What is needed to start the process |
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We basically need the completed
health insurance
application (download
here
or have a
hard copy
sent to you), and the first payment to the
carriers for at least one month's worth of
premium. If there are medical records
needed, they will request them directly from
the doctor. This completed information can
be expedited by faxing (831-624-2902) us a
copy of the app and check, and then sending
the original in the mail:
Goodacre Insurance Services
316 Mid Valley Center #283
Carmel, Ca 93923
Blue Cross has an
online application
and credit card option as well. More
information on
applying for health
insurance.
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How long does it take |
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There are two different scenarios. If the
applicant is in good health and there isn't
much the
health carrier
wants to check into, we usually hear back in
one to two weeks. If the volume of
applications is running high in
underwriting,
the time frame can be longer. If the
carrier wants further information on
something listed in the application, they
will request records directly from the
doctor and this can delay the processing
time. It usually adds another 2-4 weeks
depending on how quickly the doctor responds
back to the request.
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Do I submit payment with the application |
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The first month's premium must be submitted
with the application. This can be done with
a check made out to the carrier or via
credit card (for
Anthem Blue Cross,
Blue Shield of
California and
Health Net).
If the
application
is not approved, this initial payment will
be fully refunded.
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Is there a fee to apply |
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There is no fee to apply. Only the initial
month's premium is submitted with the
application.
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Is a physical required |
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A physical is not required...only the
completed application and first months
premium. Blue Shield may require a physical
for applicants over the age of 55 who have
not had one in the last two years.
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How can I expedite the processing |
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Anthem Blue Cross has an
online application
which tends to process very quickly.
Otherwise, you can fax your completed
application and copy of check (or credit
card section) to 831-624-2902 to start the
process immediately. You would then mail
the original if paying by check. The credit
card option just requires the faxed copy.
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Am I locked in for a period of time |
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No. The policy can be cancelled or renewed
(by payment) month to month.
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How is payment handled |
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There are a few options for payment with
either carrier.
Billing - Shield monthly,
quarterly Blue Cross bi-monthly,
quarterly
Credit Card Blue Cross allows
monthly, bi-monthly, quarterly credit card
deduction
Checking account auto-deduction
monthly deduction.
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Can I change my plan later |
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Downgrading is easy to do within the same
kind of plan such as Share 500 to the Share
1500. Upgrading is possible if you are in
good health as it is
subject to
underwriting.
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Why should I go with Goodacre Insurance
Services |
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We concentrate on
health insurance for
California |
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Individual health
insurance is insurance you buy
on your own, rather than having it provided by
your employer. 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
California companies
selling individual health insurance
typically require a review of your medical
history that could result in a higher premium or
you could be denied coverage entirely.
If you are in the market for individual health
insurance, most insurance companies have online
tools to help you find out how much individual
health insurance will cost. If you have a
chronic illness or other health condition, it
can be hard to
buy individual California
health insurance. If you have
applied for
individual health
insurance and been denied, the
information below may help you determine why you
may have been denied and if that denial was
appropriate.
Medical Underwriting
When you
apply for individual
health insurance, the
California health
insurance company uses a
process called
medical underwriting
to look at your age, sex, and health history to
decide whether it will cover you and how much it
will cost to provide you coverage.
Do all
health insurance companies
have the same
underwriting guidelines
for offering insurance?
No. Each insurance company has its own
underwriting guidelines, which are usually not
made public. However, insurance companies
marketing and selling
individual health
insurance policies in California
must file information with the Department of
Insurance pertaining to their policies,
procedures and underwriting guidelines for
offering such insurance (Insurance Code Section
10113.95 which was added by Assembly Bill 356 in
2005). We have summarized the information that
companies have filed in the questions and
answers and chart below.
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Health conditions that would automatically
not be approved;
-
Health conditions that may not be approved;
-
Height and weight standards;
-
Health history, health care service
utilization, and lifestyle or behavior that
may cause the insurance company to deny
insurance, limit the products they offer, or
charge more for the coverage.
What health
conditions will cause a health insurance company
to automatically refuse or deny my
California health
application for insurance?
There are many medical conditions that may cause
an insurance company to automatically deny or
not approve your application. These may include
the following:
-
Health problems for which you have not seen
a doctor;
-
Health problems that a doctor cannot
explain;
-
Health problems for which you have not
completed treatment.
An
insurance company may also automatically deny
your application for the health conditions
below. There may be other health conditions
that are not on this list.
-
AIDS;
-
Pregnancy,
pregnancy of your spouse or significant
other, planned surrogacy or adoption in
process;
-
Cancer, under treatment;
-
Sleep Apnea;
-
Severe mental disorders, such as major
depression, bipolar disorder, schizophrenia
or psychopathic personalities;
-
Heart disease;
-
Renal failure or Kidney Dialysis;
-
Diabetes with complications;
-
Cirrhosis;
-
Multiple Sclerosis;
-
Muscular Dystrophy;
-
Systemic Lupus Erythematous;
-
History of transplant;
-
Lymphedema;
-
Current infertility treatment;
-
Hepatitis;
-
Hemochromatosis.
What will cause an
insurance company to offer me insurance at a
higher premium rate or limit the products or
benefits I can get?
Insurance companies may offer you insurance at a
higher premium and/or limit the products or
benefits you can purchase if you had a health
problem in the past but you have recovered or
you have been without symptoms for some time.
Insurance companies will also do this for minor
health problems that you had in the past or may
currently have. Insurance companies argue that
these conditions pose a risk that it will cost
more for your health claims than if you were
completely healthy. Each application and
insurance company is different. An insurance
company may charge a higher premium or limit the
products offered for the health conditions
below. There may be other health conditions and
time frames that are not on this list.
-
Stroke, after 10 years with no reoccurring
problems;
-
Allergies, while testing is in process;
-
Ear infections, controlled with medications;
-
Lyme’s disease, without symptoms after one
year;
-
Breast Implants (non-silicone);
-
Ringworm;
-
Joint sprain or strain, recovered and no
restrictions;
-
Migraine headache, mild and infrequent with
no emergency room visits;
-
Mild depression.
Will a
California health
insurance company look at my
height and weight when I apply for insurance?
Yes. Insurance companies 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 insurance
companies use a measurement called the Body Mass
Index (BMI) to decide. If your BMI is above 39,
most insurance companies will not offer you
insurance. If your BMI is 30-39, an insurance
company may offer you insurance at a higher
premium. If you have health problems because of
your weight, such as diabetes or heart disease,
an insurance company may refuse to insure you,
even if your BMI is under 30.
Can a health
insurance company look at my smoking and
drinking history when I apply for insurance?
Yes. Insurance companies may look at smoking
and drinking history when they decide whether to
offer insurance.
The following chart
summarizes
underwriting information
that health insurance
companies have filed with the Department of
Insurance.
AB 356: Summary of Underwriting
Information filed re conditions for
which no insurance coverage will be
offered, application will be denied, or
higher premium may be charged or benefit
may be limited
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Health problems for which you have
not seen a doctor |
Automatic decline for some companies
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Health problems that a doctor can not
explain
|
Automatic decline for some companies
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Health problems for which you have not
completed treatment
|
Automatic decline for some companies
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AIDS
|
Automatic decline
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Pregnancy, pregnancy of your spouse or
significant other, planned surrogacy or
adoption in process
|
Automatic decline
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Cancer, under treatment
|
Automatic decline
|
Sleep Apnea
|
Automatic decline or higher premium will
be charged
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Severe mental disorders, such as major
depression, bipolar disorder,
schizophrenia or psychopathic
personalities
|
Automatic decline
|
Heart disease
|
Automatic decline
|
Renal failure or Kidney Dialysis
|
Automatic decline
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Diabetes with complications
|
Automatic decline
|
Cirrhosis
|
Automatic decline
|
Multiple Sclerosis
|
Automatic decline
|
Muscular Dystrophy
|
Automatic decline
|
Systemic Lupus Erythematous
|
Automatic decline
|
History of transplant
|
Automatic decline
|
Lymphedema
|
Automatic decline or higher premium will
be charged
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Current infertility treatment
|
Automatic decline
|
Hepatitis
|
Automatic decline
|
Hemochromatosis
|
Automatic decline
|
Rheumatoid Arthritis
|
Automatic decline
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Stroke, after 10 years with no
reoccurring problems
|
Automatic decline or higher premium will
be charged
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Allergies, while testing is in process
|
Automatic decline or higher premium will
be charged
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Ear infections, controlled with
medication
|
Higher premium may be charged
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Lyme's disease, without symptoms after
one year
|
Automatic decline or higher premium will
be charged
|
Breast Implants (non-silicone)
|
Automatic decline or higher premium will
be charged
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Ringworm
|
Higher premium may be charged
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Joint sprain or strain, recovered and no
restrictions
|
Higher premium may be charged
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Migraine headache, mild and infrequent
with no emergency room visits
|
Higher premium may be charged
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Mild depression
|
Automatic decline or higher premium may
be charged
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Obesity
|
Automatic decline or higher premium may
be charged
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STD (Sexually Transmitted Disease)
|
Automatic decline or higher premium may
be charged
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Of
course, if you have questions, please contact us.
That's what we are here for.
email:
help@calhealth.net
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