Getting health insurance is not about money, income or lack thereof. It is about prior health history – there are over 250 ailments someone can have been treated for in the last 10-20 years that will get an individual flat-out declined for regular coverage. With certain medical concerns, even those in the past, a carrier will issue a rider or exclusion of coverage for that condition, and any future care for that condition (including prescriptions) will not be provided.

President Clinton said no one could be declined! That particular speech and subsequent mandate related to people coming off of 18 months of military coverage, COBRA or off of a group plan too small to offer COBRA. It did not pertain to individuals coming from other individual health plans (a family plan is not a group plan – a group plan is one whereby the individual appears on the employer’s quarterly tax and wage statement and the employer pays the premium, or most of it, for the employee).

All states now have what are called “high risk pools” and these health plans cannot decline anyone so long as they can show proof that they are uninsurable. And as long as they can pay the premium. The lowest premium in Arizona is in the neighborhod of $550 per month, and as high as $750 for older applicants. You cannot move out of state with these plans – they are unique to that state.

What makes a person uninsurable?

* Medical conditions that can “come and go” or can go into remission  – i.e., MS, lupus, chronic fatigue…..
* Certain tumors that are benign (a tumor can still grow, become a problem, invade other areas of the body, and/or require surgery); ability to get insurance depends on the type of tumor, but there would be no coverage for the condition
* Someone who has been told to have a particular diagnostic exam and has not had it can be declined; someone who has surgery pending that has not yet been performed - don't try to change carriers while in the middle of any medical diagnostics
* Immune system disorders such as fibromyalgia, Crohn’s disease, Sjogern’s, rheumatoid arthritis, chronic fatigue, lupus, MS, muscular dystrophy, ulcerative colitis….
* A pregnancy in progress, unless you can qualify for some form of Medicaid (based on poverty level income) or get a job that will offer immediate coverage on a group plan)
* Too many medications for the same condition: why three anti-depressants? Why four medications for hypertension? Why an applicant total of seven or eight medications?
* A diagnosis on record of clinical or chronic depression, manic-depression or bi-polar.
* Any history of heart attack, angioplasty, stints (of almost any kind), pacemaker, stroke, TIA, insulin-dependent diabetes, hepatitus C, auto-immune disorders (HIV, AIDS), internal cancer within 10 years – many carriers want a 15 year window on melanoma… basal cell is not a problem anywhere
* History of speeding tickets or DUI's - one DUI in a five year period can drastically affect one's ability to get helath insurance - and most carriers do run a Dept of Motor Vehicle check. An Extreme DUI can result in no coverage fior up to five years with some carriers.
* Overweight by more than 75 pounds will get you rated very high if not declined, depending on the carrier. Add overweight to conditions requiring medications and that makes coverage even more costly and difficult to obtain. No matter how healthy a person thinks they are, the body knows it is carrying 50, 75, 100 or more pounds of extra pressure on the vital organs. Overweight is never healthy and insurance carriers won’t cover conditions that are in the power of the applicant to change
* Combinations of certain conditions: for instance, more and more carriers are declining the combination of hypertension, high cholesterol and smoking, or the combination of diabetes and hypertension or high cholesterol (yes, some carriers will take an adult-onset non-insulin diabetic - IF there are no other medications being taken), the combination of overweight, smoking and either hypertension OR high cholesterol…. What the carriers see when it comes to cholesterol/smoking/hypertension and/or weight issues, is someone who is not doing what they could to be helping themselves. Insurance companies aren’t going to do the work that the patient could be doing to help themselves.

Are there exceptions to the above? Yes - group insurance through an employer. Even then, many carriers are now placing a one year waiting period on any condition for which the applicant has received medical advice, treatment, consultation, surgery or medication in the prior 12 months if the applicant cannot show proof of having been covered under some sort of insurance plan up to the day they go on the group plan.

And why is that? Because more and more people are taking jobs just to get the health benefits - if not for themselves then for a dependent. Group insurance was never meant to cover families, and that is why the rate for dependent coverage is so high on group plans. When a new employee has a serious medical condition, the rates for the employer won’t change significantly at that point. However, when renewal times rolls around for that plan and its participants, the medical claims of each member of that group in the previous year will have a very significant impact on the next years’ rates. Unfortunately, that is why many smaller employers drop their group plans: the premiums have increased anywhere from 25-30% because two or three members of the group had major medical expenses. The insurance covered them, which is what it was meant to do - but insurance companies use the premium payments to pay their claims. If you have a premium of $325 per month and have a $120,000 by-pass, who is paying for the balance? All the other insurers, the ones who don’t have claims. There is no other source of income to a carrier. When a carrier starts paying out more in claims than it collects in premiums, the carrier has two choices: raise premiums enough to compensate for the shortage, or withdraw from the state. This is true whether you have group or individual coverage.

What really impacts a group plan’s rates is when a new employee comes on board, a family member has major surgery, then the employee quits his job… Even though that employee isn’t there when the health plan comes up for renewal, the claims that were paid still exist and yes, the health plan premium will take the hit, which will increase the cost to the employer and the employees.

The above reasons are why one should find a good health plan and not always rely on employers to cover them - what if you lose that coverage? COBRA is only good for 18 months - and only has to be offered by employers who have 20 or more employees - and HIPAA, which follows COBRA for the uninsurable, is very costly.
 

The above reasons are also why one should try their best to stay in good health: cut back on the alcohol or tobacco (incidentally, a cigar once a week still makes you a smoker to an insurance company, as far as rates go - and the average rate increase for tobacco usage is 30%), watch the diet, don’t reach for medication every time something goes wrong, get regular check-ups before minor issues become major problems.

Mostly, take responsibility for paying the little things and not asking the insurance carrier to pay for every little thing. The more the carriers have to pay for, the more the rates will continue to soar.
 

See article this website on “Upset with High Premiums? Take Responsibility!”