Denial due to a pre-existing medical condition

High Risk Pool Plan*

NEW YORK  

The New York Department of Insurance can help New York residents with health insurance questions.  The web site is www.ins.state.ny.us, address is New York Department of Insurance, New York City, 25 Beaver Street, New York, NY  10004, (212) 480-6400 or (212) 480-5242. 

In New York State, all individual and small group policies are community rated and have open enrollment. This means that insurance companies cannot refuse to enroll someone because of a pre-existing medical condition.  So, anyone can purchase individual or small group policies in New York.  However, if the person has not had creditable coverage for 63 days before they purchase New York coverage, the health plan can exclude the condition as a pre-existing condition for up to one year. 

The website has information on health plans which women can purchase if they do not qualify for ‘Healthy New York’.

NORTH CAROLINA  

The North Carolina Department of Insurance can help North Carolina residents with health insurance questions.  Contact information:  North Carolina Department of Insurance, P.O. Box 26387, Raleigh, NC  27611, web site http://www.ncdoi.com/Industry/Life/LHContacts.asp. 

Unfortunately, we do not have any state insurance programs in place in North Carolina that would assist women with in this type of situation, unless they qualify for State assistance and the Medicaid program. 

The Federal and State Health Insurance Portability and Accountability Act (HIPAA) would come into play if the woman was coming off of group insurance coverage or trying to get group coverage after being insured individually.  In that instance, pre-existing conditions are covered if the person had qualifying coverage during the previous 18 consecutive months. 

For more information, contact the Life and Health, Consumer Services Division.

NORTH DAKOTA*       

The North Dakota Department of Insurance can help North Dakota residents with health insurance questions.   The address is North Dakota Department of Insurance,  600 E. Boulevard, Dept. 401, Bismarck, ND 58505-0320, (701) 328-2440 or Consumer Hotline at 1-800-247-0560.

For more information on North Dakota high risk pool - phone number 1-800-737-0016. 

OHIO          

The Ohio Department of Insurance can help Ohio residents with health insurance questions.   The address is Ohio Department of Insurance, 2100 Stella Court, Columbus, Ohio 43215-1067, phone (614) 644-2658, (614) 644-3743 (Fax).

OKLAHOMA*    

The Oklahoma Department of Insurance can help Oklahoma residents with health insurance questions.   For more information on the Oklahoma high risk pool - phone number is 1-800-255-6065 or (913) 362-0040.

OREGON*

The Oregon Department of Insurance can help Oregon residents with health insurance questions.   Mailing address is Oregon Insurance Division, P.O. Box 14480, Salem, OR 97309-0405, phone (503) 947-7980. 

Ø      Anyone with a medical problem can get insurance in Oregon after being rejected by the Individual market.   Information about the Oregon Medical Insurance Pool (OMIP) is available at the following URL http://www.omip.state.or.us/, phone toll-free in Oregon (800) 542-3104 or in Salem (503) 373-1692. 

Specific medical criteria used to select applicants are not regulated.   Each carrier has their own medical criteria unique to their business model.

PENNSYLVANIA*       

The Pennsylvania Department of Insurance can help Pennsylvania residents with health insurance questions.  To contact the Department:  Pennsylvania Department of Insurance, 1326 Strawberry Square, Harrisburg, PA 17120, phone 1-877-881-6388.  Web site URL is http://www.ins.state.pa.us/ins/site/default.asp.   

Ø      Women should first contact their Local County Welfare Assistance Office in which they reside.  Medical Assistance Spenddown is one of the options available.   Medical assistance may be available for persons who have large medical bills.  The Medical Assistance would help pay some of the medical costs.  There are various eligibility requirements for each option.

Ø      Pennsylvania has the AdultBasic Plan for individuals who have been denied health insurance because of a pre-existing medical condition.   If an individual is eligible for AdultBasic coverage (no health care coverage, age 19 –64, income guidelines, lives in Pennsylvania, and is a U.S. citizen) their name is put on a waiting list on a first come, first served basis.  The insurance ‘contractor service area’ is dependent on the Pennsylvania region in which the applicant resides. http://www.ins.state.pa.us/ins/cwp/view.asp?a=1278&q=527040 

Ø      Persons from the waiting list will be notified when they are enrolled in the AdultBasic program.  They will have to submit a monthly payment. 

Ø      There is an option to purchase AdultBasic coverage at the Insurance Department cost.  For more information on AdultBasic:        http://www.ins.state.pa.us/ins/cwp/view.asp?a=1278&Q=527054&insNav=|

RHODE ISLAND 

The Rhode Island Department of Insurance can help Rhode Island residents with health insurance questions.  Phone number is (401) 222-2246.

Most people who have recently had insurance can get insurance without exclusions or limitations for pre-existing conditions. However, people who are not eligible for coverage through employment and who have not recently had coverage will likely be subject to exclusions for pre-existing conditions.

Rhode Island residents may want to contact the Department of Human Services, the Department of Health, or the Department of Elderly Affairs to find out what is available in their state.

SOUTH CAROLINA*

The South Carolina Department of Insurance can help South Carolina residents with health insurance questions.   

South Carolina has a program under the South Carolina Health Insurance Pool, which is guarantee issued.  The pool can be contacted at 1-800-868-2500 ext 46401 for information on eligibility and cost. 

SOUTH DAKOTA*

The South Dakota Department of Insurance can help South Dakota residents with health insurance questions.   The address is South Dakota Department of Insurance,  445 East Capitol, Pierre, South Dakota 57501, telephone 605-773-3563, fax number 605-773-5369.  The website is www.state.sd.us/drr/insurance.   

All individual major medical insurance policies in our State are medically underwritten.  This means that each insurance company has it's own guidelines regarding existing medical conditions when they determine whether or not they issue a policy.  If an applicant does not meet those guidelines, they may require the applicant sign a "rider" or "amendment" to the policy which would exclude benefits for that particular condition or they may deny the applicant altogether.  The particular condition you are referring to, uterine fibroids, may or may not be excluded under every company's guidelines. 

Under a group major medical policy, a condition cannot be excluded for a period longer than one year (18 months if the insured is a late enrollee). 

South Dakota has seven major medical insurance companies marketing these types of policies.  Contact the ‘Consumer Complaint’ section for more information.  South Dakota high risk pool (605) 773-3148.

TENNESSEE*      

The Tennessee Department of Insurance can help Tennessee residents with health insurance questions.   Phone number is (615) 741-6007.

In short, no such program exists.  As you may know, federal (and state) laws exist to protect those who maintain continuous insurance coverage from pre-existing condition exclusions.  Once they've become uninsured for a period of time, nothing in our law requires insurers to write folks having current or past health problems or to cover their current or recurrent health problems (with perhaps very few exceptions).   

TennCare (revised Medicaid program) does provide insurance for those with little to no financial resources who have been denied coverage in the private marketplace.  For those with financial resources and current or past health problems, there is nothing this agency can do but provide them with a list of companies in the individual insurance market (which are available on our web site) and hope they can find someone willing to write them.  There remain many who have the money to pay premiums but for health reasons cannot find any company willing to insure them.   We recommend you contact the Bureau of TennCare about eligibility requirements, phone (615) 741-8642.