To be eligible for individual and family health insurance coverage,  you must have been a resident of the United States for 3 months prior to enrollment, be under age 64 ¾, and not be eligible for Medicare part A or B. If a dependent child, must be under age 19 or if between the ages of 19-23 be considered a “dependent” under IRS guidelines. A newborn child of a member, spouse or enrolled domestic partner may be added without proof of insurability within 60 days of birth.

This is the amount you have to pay out of pocket before the insurance company starts paying for benefits. Generally speaking the higher the annual deductible the lower your monthly premium will be. A high deductible plan allows you to save money in a Health Savings Account and pay for eligible medical expenses with pre-tax dollars, while taking a tax deduction for the amounts you save every year in a Health Savings Account.

In addition, to the annual deductible, you will often have to share in the cost of medical services received. For example, office visits may have a $10, $20 or $40 co-payment and hospitalization and diagnostic testing may have a 20%, 30% or higher co-payment or co-insurance amount. Your annual out of pocket co-payments or co-insurance amounts will be capped by the annual out of pocket maximum called out in the plan of your choice.

This amount represents a cap on your share of medical expenses on a yearly basis. It is usually the sum of your annual deductible plus any applicable co-payments up to the cap applicable in you health insurance policy.

Once your application is received it is submitted to the insurance company’s underwriting department. The role of underwriting is to determine whether insurance company can accept your application and “underwrite” the risk of future unexpected medical expenses. Your application may be either accepted at standard insurance rates, rated up (accepted but at a higher monthly premium) or declined due to any pre-existing conditions.

Once your individual application is received, it will be reviewed for underwriting purposes at the insurance company. Your health insurance policy may be issued either at the standard rate (as quoted), or rated up (higher price depending on your health condition), or declined due to a variety of factors. If declined, you may be eligible for Major Risk Medical Insurance coverage.

Occasionally and depending on your health condition, medical history and/or a combination of health related factors, the insurance company may decline your application. In this case, you may be eligible for Major Risk Medical Insurance Program coverage (MRMIP) or other plan depending on your individual circumstances. Most insurance companies offer Major Risk Medical Insurance, and as the name implies, premiums for these plans tend to be higher.

Say you were covered under an employer sponsored plan for a minimum of 18 months and have now exhausted your continuation of coverage under Cal-COBRA or COBRA, you may be eligible for a HIPAA plan provided you have lost coverage within the last 63 days and are not eligible for Medi-Cal or Medicare.

No, however you must be able to demonstrate that you have been a legal US resident for a period of at least three 3) months prior to applying for coverage.

COBRA stands for the Consolidated Omnibus Budget Reconciliation Act. This law was enacted in 1985 and requires employers with >20 employees to provide continuation of group health insurance coverage to employees and their dependents for a period of 18 months subject to certain “qualifying” events. Many states have adopted this legislation for small businesses with less then 20 employees.

Under current health insurance guidelines, a person applying for an individual health insurance plan may be declined if he/she has certain pre-existing medical conditions. In that case, COBRA coverage is recommended since it is guaranteed issue and a laid off employee and his dependents may not be declined coverage. This is an important safety net and a key feature and advantage of COBRA coverage.

The most common qualifying event involves termination of employment (without cause). Other qualifying events include reduction in hours worked (from full time to part time), divorce or legal separation, or the loss of dependent status.

Yes. Coverage may continue for up to 29 months if an individual becomes disabled and qualifies for Social Security disability benefits. In addition, an employee’s dependents may be eligible for an extension of up to 36 months of COBRA under certain qualifying events including death of employee, divorce or legal separation or when employee becomes eligible for Medicare benefits.

Typically, an employee has to pay 102% of what his employer used to pay per month for his coverage. In general, COBRA coverage tends to be more expensive then individual coverage, but represents an important safety net for any eligible person who may not otherwise qualify for an individual plan due to a pre-existing condition. Even with passage of recent COBRA subsidy legislation, it may still be possible to save money by buying an individual health insurance plan. At Clarify, we will help you determine if you are better off with an individual or COBRA plan you may be able to extend your COBRA coverage another 18 months depending on whether your group plan was self-funded or not. An employee who was disabled at termination, may be required to pay 150% of the monthly group rate after the initial 18 months of coverage.

Once you are laid off, your group or group administrator is responsible for advising you of your eligibility for COBRA coverage. You will then have 60 days from date of notification to elect COBRA coverage. Your first bill will be due and payable, 45 days after you elect COBRA coverage. You will be required to pay for the premium retroactive to the qualifying date. This means that an individual has up to 105 days to decide on COBRA without losing the safety net provided by COBRA’s guaranteed coverage.

If your group plan was discontinued because your employer is no longer in business and/or group health insurance premiums were not paid, you will not qualify for COBRA continuation of your group health insurance coverage. Call one of Clarify’s health insurance agents to explore all your options. There is no added cost or obligation to you when you let Clarify Insurance help you explore all your options.

Sensible Health Insuance