Pre-Existing Medical Conditions: Your Individual Health Insurance Options

For those of us with any sort of pre-existing medical condition, too young to qualify for Medicare Benefits, doing just a little too well to qualify for a Medicaid Plan, too broke to afford a steep out-of-pocket privately sponsored health care premium or too “self-employed” to be a participant in an affordably-priced group sponsored medical program, today’s health-insurance marketplace can seem a bit daunting and more than a little inaccessible.

None of the factors listed above has the capability to keep consumers from getting health insurance coverage through one of the nation’s major indemnity carriers in and of itself, they do work to hamper the efforts of sixteen million or so of us searching for a private health policy to buy into that won’t be prohibitively expensive.

The need to buy into a health insurance plan of our own makes us the proverbial “unwanted children” of the medical insurance marketplace . . . The employees of smaller firms unable or unwilling to offer healthcare benefits, the self-employed, those of us who are lingering between jobs, recently divorced or widowed individuals whose situation has lost them their spouse’s group health coverage, young adults who’ve moving or being moved off of their parents’ medical policies or those of us who’ve decided to retire early and thereby lose our group health coverage before turning sixty-five and becoming eligible for Medicare . . . are all faced with the need to buy into an individual or family policy and entering into a peril-fraught marketplace wherein both good advice and reasonable prices can be scarce.

There are fewer and fewer major health insurers interested in offering their services to individuals such as those described above, and their reasons for that are fairly straightforward.

With employer paid group care policies, both the company’s sicker and their healthier employees are mixed into the same risk pool, and the premiums paid by the healthier individuals tend to cover the costs of the claims of the ill. But with an individual health plan, there isn’t an alternate revenue stream subsidizing a participant’s care needs. And, as a direct result, many health providers claim that even their ever higher premium charges aren’t sufficiently covering the costs of medical care when an individual policyholder falls ill or has an accident. Many carriers either try to avoid directly writing health policies for the individual market, or try and employ strategies designed to limit their risk as well as individual consumers’ access to the coverage for the healthcare they need.

None of which means that there aren’t good deals out there, but rather that they may vanish once individuals are sick or get injured and file a claim. Just as with any other marketplace, effective comparison shopping is key, but there also a few things that individual health care consumers can look out for as they struggle to get and stay insured:

Coverage for a Pre-Existing Illness

The majority of individual care policies are medically underwritten. What that means is that some providers take a closer than average look at applicant’s medical records then turn down those individuals with health conditions considered to pose too much of a risk. While its not odd that most insurers would deny coverage to an individual with a serious condition such as cancer or coronary artery disease or diabetes, but consumers faced with the sort of benefits provider who also turns down applicants suffering from ailments as minor as ear infections or hay fever will want to look elsewhere for care.

Gaps in the Regulations

There are a small number of insurance carriers offering healthcare plans that appear to be group benefits when they aren’t. Providers arrange for a master benefits policy under the auspices of what’s known as a “group discretionary trust,” in states where there are few if any regulations governing the kinds of health policies that individual consumers may be sold therein. Such carriers then offer health coverage in other states, but such policies are solely governed by the lackluster laws of the state holding the master policy.

Consumers faced with business practiced in such a fashion can only be advised to keep looking for a reliable healthcare carrier.

The Cracks in the System

In 1996,when the Congress passed the Health Insurance Portability and Accountability Act or HIPAA, they mandated that every state provide a source of last resort for individuals to buy into a health insurance plan.

Unfortunately, HIPAA really didn’t come too close to solving the health care system’s problems and in actual fact left a dismal market-place virtually unchanged. HIPAA laid out a set of minimum standards for coverage of last resort, but did not ensure that anyone who needed health insurance coverage would have access to a policy irregardless of their health status. The resulting hodgepodge of insurance regulations that vary from state to state has left consumers with the need for unbiased sources from which to both their health plan quotes and their health care information.

It’s a difficult truth that the individual health insurance marketplace offers consumers few if any teammates with which they can spread out the risks and overall costs of paying for health and major medical care, and individuals who require coverage are often burdened by self-employment, expensive pre-existing health conditions or age group and indemnity carriers do not typically do business in a manner designed to sell policies at a loss.

Consumers require more than simply a piecemeal slate of reforms to confront and solve the substantial problems facing them as they search for health insurance coverage. What they clearly need is a place, an impartial information portal, where they can let the nation’s health system’s most consistent asset, its sheer competitiveness, work for them rather than against them and get the help they’ll need to find the insurance they need.

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