Daniel MacDonald was able to get health insurance in the private market… (Lawrence K. Ho / Los Angeles…)
Amy Reiley had resigned herself to joining the ranks of the uninsured. The part-time L.A. resident and owner of a boutique cookbook publishing company had a group insurance plan that for three years covered her and another full-time employee.
But when Reiley's employee became eligible for Medicare, she lost the group policy and was left to search for insurance on her own.
FOR THE RECORD: Preexisting conditions: In the Sept. 6 Health section, an article on health insurance for people with preexisting medical conditions incorrectly stated that individuals could access annual records on their use of prescription drugs by contacting the MIB Group. The MIB Group does not compile personal pharmacy information. To access that information, consumers can contact Milliman IntelliScript at (877) 211-4816 or at www.rxhistories.com /contact_us.html; or MedPoint Compliance, Ingenix at (888) 206-0335 or www .ingenix.com/contactus/. —
Reiley, in her 30s, has a history of headaches resulting from neck spasms, which she manages with a muscle relaxant. Because of her condition, all her applications for insurance were denied.
"I tried two companies and looked into what the state had to offer and there really wasn't anything I could do," she says.
For people with preexisting medical conditions, looking for health insurance in the private market may feel like the ultimate fool's errand. A 2009 report by the Commonwealth Fund found that 36% of people who tried to buy insurance in the private market were denied coverage or charged more because of a preexisting condition or had the condition excluded from their coverage. Cancer, heart disease, diabetes, rheumatoid arthritis and drug and alcohol dependency are certain to be automatically rejected by insurers — and even people who have minor conditions may find the search for an insurance plan tricky.
When the health reform law takes full effect in 2014, insurers will no longer be able to deny coverage to people with preexisting medical conditions. In the meantime, new federally funded high-risk pools for the medically uninsurable have been established. To qualify, you have to be without insurance for six months. And you must show you have applied for, and been denied, insurance in the private market.
But if you have a preexisting condition and don't qualify for the high-risk pools, it still pays to explore options in the private insurance market. "Don't assume if one insurer rejects you that they all will," says Anthony Wright, executive director of Health Access California, a statewide advocacy group. Reiley, for example, did try again, this time with an experienced insurance broker. Although she paid more because of her condition, she found a plan that is cheaper than what she was paying for as a member of a small group.
With proactive steps as well as insight into how insurers decide who they'll cover, you can improve your chances. Tips:
Know your rights
If you've exhausted your 18 months of COBRA benefits available after leaving a job, federal law guarantees you a policy from private insurers. In some states (including California), insurers are permitted to consider the state of your health when determining the premium, says David Rousseau, health policy expert at the Kaiser Family Foundation, a nonprofit healthcare organization. But you can't be turned away.
The type of policy available differs among states; in California, carriers must offer their two most popular plans. Check with your state's department of insurance to learn the rules where you live (www.naic.org/state_web_map.htm).
Bill Robinson, vice president of legislation for the California Assn. of Health Underwriters, urges consumers to make sure they receive and safely file a certificate of "credible coverage" sent by their previous insurer. This is the only document that proves to a new company that you had prior coverage. "Just about all companies may refuse to pay a claim for pre-existing conditions until the individual gets the certificate. Don't throw it away," Robinson says.
Gray-area conditions
A number of common medical conditions fall into a "gray area" of medical underwriting (the process wherein insurers review your age, gender and health history to determine how much it will cost to insure you) that won't necessarily disqualify you from getting coverage, says Amir Mostafaie, consumer health insurance expert at eHealthInsurance. Examples are allergies, asthma, mild depression, well-managed high blood pressure, and controlled migraines and sleep apnea.
