It's important to look at a carrier's policies and restrictions about pre-existing conditions, waiting periods, and exclusions because they can vary from company to company. This is just a summary in plain English.
First, what is a condition that already existed? Here's what the official definition says:
Condition that was there before
Any illness or health problem for which you saw a doctor or got treatment in the six months before you got health insurance. Group health insurance policies cover pre-existing conditions after you've had them for six months, and individual policies cover them after you've had them for a year. Refer to CIC Section 10198.7. Creditable coverage must be counted toward any pre-existing condition exclusion in an individual or group policy.
It's basically a medical condition, illness, or injury for which you are being treated, have been treated in the past, or are currently being treated. How an insurance company looks at conditions that were already there before depends a lot on the type of insurance.
Individual and family health insurance in the state of California.
This kind of insurance is based on your health, so you have to be healthy enough to get it. Most of the effect comes from pre-existing conditions, which change coverage in two ways.
First, you have to be healthy enough to qualify for coverage, so that a company can raise your rates or deny or delay coverage based on your pre-existing conditions. They usually have underwriting guidelines that tell them how to look at different things. The final decision is made by the underwriter, who decides whether or not to approve health coverage based on information in the health application or medical records (if requested).
For some problems, the health insurance company may want a certain amount of time to pass before they cover the problem. For simpler situations, a good rule of thumb is between 6 months and a year (simple broken bone, infection, etc). Some problems are thought to be so bad that they can never be covered.
If you can't get individual or family health insurance in California, the state offers options for the uninsured, like MRMIP.
After approval, pre-existing conditions can affect Individual Family California health insurance coverage in a second way. If you are approved for coverage, you may have to wait up to 6 months before you can get treatment for pre-existing conditions or get paid for them. This is true if you have never had coverage or if your coverage has been cancelled for more than 62 days. Basically, they will count the time spent on a previous qualified plan (which could be an individual plan, a small group plan, or a short-term plan) toward a six-month waiting period for pre-existing conditions.
With Individual and Family coverage, the tier goes up.
If an insurance company doesn't turn down coverage because of a pre-existing condition, they can raise rates. Quotes for individual California health insurance show that Tier 1 is the best rate. The normal rate for Tier 2 is usually 25% higher than this rate. Tier 3 is usually 50% more expensive, and Tier 4 is usually 100% more expensive. Some carriers raise prices in different ways. Blue Shield of California, for example, has a Tier 5 that is much higher. This tier increase is not set in stone, and you may be able to get it taken away or lowered in the future after enough time has passed (assuming you are in otherwise, good health). We suggest sending in the required change of coverage form every three to four months until this tier can be raised.
Small group health insurance in California and conditions that were already there.
For Small Group, there are some important ways in which pre-existing conditions are dealt with differently. Most of the time, there are no waiting periods for pre-existing conditions with HMOs. Neither HMO nor PPO plans in California usually have waiting periods for maternity care. Aside from that, the waiting period of six months is the same as for individual plans. Send all claims through the carrier, no matter what, and let them decide how long you have to wait.
Small groups don't 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 how healthy the group is. The RAF is the name for this (Risk Adjustment Factor). The standard rate is 1.0 RAF. It would be 10 percent more than 1.1 and 10 percent less than.90. The more people in your group, the more likely it is that your RAF will go down. Some carriers automatically charge 10 percent more for small groups because there are fewer people to share the risk with.
Some conditions can't be met
California law says that carriers can't turn down an applicant based on a condition they have (if it's a covered benefit) like they can in other states. This is both good and bad. On the one hand, a new enrollee doesn't have to worry about a condition coming back and getting their coverage taken away. The problem is that a person might not be able to get coverage at all, which would defeat the purpose of getting rid of exclusions in the first place. This is called the "law of unintended consequences." Keep in mind that this exclusion only applies to one person's condition that was already there. Some plans are made to not cover things like prenatal care or brand-name drugs. The summary and explanation of benefits of a plan will list the standard things that are not covered.
It's important to look at a carrier's policies and restrictions about pre-existing conditions, waiting periods, and exclusions because they can vary from company to company.
