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Question: I live in California and need to purchase health insurance because my COBRA benefits are expiring. I have a pre-existing condition and am worried about finding coverage for my illness. How long can a health insurance company exclude coverage for my disease?
Answer: California residents, who have previously held group insurance, or continuation coverage such as COBRA, are protected by federal law from pre-existing condition exclusions.
The Health Insurance Portability and Accountability Act (HIPAA) guarantees certain individuals the right to buy individual medical coverage without any pre-existing condition exclusions. This guaranteed coverage applies if all the following criteria are met:
- You have at least 18 months of medical insurance without a significant break (more than 62 days) in coverage
- Your last medical coverage came from a group insurance plan
- You lost your group coverage for a reason other than fraud or non-payment of premiums
- You are not eligible for COBRA coverage or you have exhausted your COBRA benefits
- You are not eligible for Medicaid, Medicare, or any other group health insurance plan
Because COBRA is a group plan, if you meet the other criteria, you should be able to purchase individual medical insurance without any pre-existing condition exclusions. If you are not eligible or you wait more than 62 days to begin your individual plan, the following pre-existing condition exclusions may apply under California law:
- 12 months for plans covering one or two people
- 6 months for family plans covering three or more people
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| A premium is the monthly cost of keeping your insurance policy in effect. Health insurance premiums are determined by a variety of factors, including your medical history, your lifestyle, and your current health status. |
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| A deductible is an amount of medical expenses you are responsible for paying before your insurance starts covering you. A common deductible is $500 - this means you would be responsible for paying the first $500 in medical bills before receiving coverage. Having a higher deductible usually means you enjoy lower monthly premiums. |
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| A co-payment is a fixed-dollar amount that you are responsible for paying for a particular medical service. For example, many plans have $20 co-payments for doctor's visits. This means it only costs you $20 to see a doctor. |
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| Coinsurance is an amount of the cost of a medical service that you are responsible for paying. Unlike a co-payment, which is a fixed-dollar amount, coinsurance is expressed as a percentage. For example, many insurance plans have 20% coinsurance for hospital costs — meaning you pay 20% of the total cost of a trip to the hospital. |
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| An out-of-pocket expense is any cost you have to pay yourself when receiving medical care. This includes your deductible, co-payments, and coinsurance. Most health insurance policies have an annual maximum out-of-pocket expense. Once you’ve paid out enough money to meet that maximum, your insurance company will pay the rest of your medical costs. |
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| Managed care is a form of health insurance that stresses preventive medicine and affordability. In a managed care plan, you typically choose a “Primary Care Physician” who is responsible for approving specialist and hospital care. Managed care was originally introduced as a way to control healthcare costs. It's now the most common form of health insurance in the United States. HMOs and PPOs are examples of managed care. |
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| Health Savings Accounts aren't health insurance plans. Instead, they are a financial tool designed to help make your healthcare more affordable. The money you deposit in an HSA is tax-free. You don't pay taxes on qualified withdrawals, either. In effect, it's like getting extra money from the government to pay for healthcare. To open an HSA, you first have to purchase a high deductible health plan. |
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| Having health insurance isn't just about paying medical bills. It's about knowing that you'll always have access to quality care. Health insurance makes seeing the doctor easy and affordable - and that means you're more likely to stay healthy. |
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| The best way to explore your health insurance options is to get the advice of a professional agent. Our instant quote tool will let you get started comparing plans in just minutes. When you request free quotes. To learn more about which options are right for you, contact us - we're always happy to answer your questions. |
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| That depends on who you are. There is no single best policy for everyone. To find out which plans are right for you, fill out this short form and get your free online quotes. |
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