Frequently Asked Questions - Individual and Family Health Insurance

Individual and Family health insurance is different from Group (Company) insurance in that they can decline and or change rates based on your health at the time of application.  Below we have some common reasons for difficulties in getting approved but first a few quick tips regarding qualifying for coverage.
 

• Some situations require time away from the condition in order to qualify.  For simple situations, a 6 month period sign, symptom, and treatment free is a good estimate.  This can also pertain to medication.  
• It is not uncommon to be declined by one carrier and accepted by another even though the carriers have very similar underwriting requirements.
• If we are declined by a carrier, we may lose our Short Term option.  If there is an issue, and you have no coverage, we recommend getting Short Term coverage first and then apply for the permanent plan. 
• Brand name medication are heavily scrutinized these days due to the cost associated with their use.  
• If you are currently on Cobra, it typically makes sense to apply for coverage as there is no down side.  You can remain on your Cobra if the coverage is not approved.  Cobra is usually quite expensive.
• The carriers can offer a split approval where one member is not approved but the rest of the family is.
• The carriers are mainly looking at current/recent and ongoing situations.  We all have a medical history but situations that are stable, from which time has passed, typically do not cause problems.
• If you are exhausting or losing Cobra (continuation of group coverage) you may be eligible for HIPAA.  Please check with us if this sounds applicable.

  Some common reasons for declination/deferrals of coverage

  • currently pregnant or an expecting father 
  • multiple medications especially brand name
  • recent (last 6 months including physical therapy) injury
  • recent (last 2-3 years) treatment for heart disease, diabetes, cancer, immune system disorders, or any other serious medical condition
  • height/weight outside guideline range
  • multiple conditions/injuries/illnesses

  More information on Individual and Family California health insurance

  Individual health insurance is insurance you buy on your own, rather than having it provided by your employer.  Please examine your options carefully before declining group coverage or continuation coverage, such as COBRA, that may be available to you.  You should be aware that Anthem Blue Cross requires a review of your medical history that could result in a higher premium or you could be denied coverage entirely.

  If you are in the market for individual health insurance, Anthem Blue Cross has online tools to help you find out how much individual health insurance will cost.  If you have a chronic illness or other health condition, it can be hard to buy individual California health insurance.  If you have applied for individual health insurance and been denied, the information below may help you determine why you may have been denied and if that denial was appropriate.

  Medical Underwriting

  When you apply for individual health insurance, the California health insurance company uses a process called medical underwriting to look at your age, sex, and health history to decide whether it will cover you and how much it will cost to provide you coverage.

No.  Each insurance company has its own underwriting guidelines, which are usually not made public.  However, insurance companies marketing and selling individual health insurance policies in California must file information with the Department of Insurance pertaining to their policies, procedures and underwriting guidelines for offering such insurance (Insurance Code Section 10113.95 which was added by Assembly Bill 356 in 2005).   We have summarized the information that companies have filed in the questions and answers and chart below.

• Health conditions that would automatically not be approved;
• Health conditions that may not be approved;
• Height and weight standards;
• Health history, health care service utilization, and lifestyle or behavior that may cause the insurance company to deny insurance, limit the products they offer, or charge more for the coverage.

Yes, you may go to a non-network provider, but your out-of-pocket costs will be substantially less if you go to a Participating Provider. Please consult your Evidence of Coverage. You can find a network provider here.

1. Go to our Provider Finder and follow the prompts to retrieve your health plan's network providers. If you want directions to a specific provider, simply click on the provider's name and you are linked to an area map that shows various routes to the provider's location.
2. Look in the printed Anthem Blue Cross PPO Directory. You can get a provider directory mailed to you by calling Customer Service at the toll-free number on your ID card.
3. Call the toll-free Customer Service number on your ID Card.

Yes. We recommend that you carry your ID Card at all times. You may need it in case of emergency. You may be required to present your ID Card at your doctor's office or at a hospital.

Please use the Member Services feature to order ID Cards. Or, call the toll free Customer Service number on the back of your ID Card to order new ID Cards. Customer Service is available from 8:30 a.m. to Midnight, Monday through Friday, Pacific time. (800) 333-0912

Your children remain covered if they are unmarried, under 19 years old, or 22 years old or younger as long as they qualify as dependents for income tax purposes and are full-time students (12 or more credits) at an accredited college, university, vocational or technical school. Anthem Blue Cross requires written proof of student status annually. Please see your Evidence of Coverage booklet/policy for more details. The age limit for children to remain on your policy is 23 years old. At that time, they may transfer to their own Individual plan.

You may change your existing benefit plan as often as you like. There are different steps involved in changing your plan depending on if you are upgrading or downgrading your plan. If you have questions on changing your existing benefit plan, please contact a dedicated Customer Service Associate at the number on your ID card or contact your broker.

Anthem Blue Cross and Blue Shield of California are separate, competing companies that offer comprehensive plans at the Individual/Family health insurance and Small Group health insurance. Provider Networks Both companies have extensive doctor and hospital lists with 48,000 doctors and 400 hospitals up and down the state. Typically the lists overlap with doctors/hospitals participating in both. Occasionally there will be a doctor who participates with one company but not the other so it's best to check on your doctor. Financial Strength This really is the main reason to go with the "Blues". Smaller or less efficient carriers are having difficulties, with some filing for Bankruptcy. If you are with a smaller carrier that is offering significantly reduced costs, they almost definitely raise rates, lower benefits, and/or leave the market entirely. If you have developed health conditions, the other carriers will not pick you up at that time. Anthem Blue Cross is owned by Wellpoint, Inc named the most admired health care carrier in the nation three years in a row. Blue Shield is a close second.

To add Family Members

Spouse:

You will be required to submit a completed application for the spouse that references the enrolled Subscriber’s Certificate Number. The spouse is subject to underwriting.

Newborn Child:

For coverage to continue beyond the automatic thirty one (31) days from the date of birth to an already enrolled Subscriber or Spouse, Anthem Blue Cross must receive within 60 days of the Child’s birth, an application to enroll the Child and any additional charges due.

Adopted Child:

Anthem Blue Cross must receive an application to enroll the Child within 60 days of acquiring the Child in order for coverage to continue beyond the first thirty one (31) days from the date of adoption. Any additional charges can apply and are due.

Children under 19 that are not newborns or newly adopted:

You will be required to submit a completed application for that(those) child(ren) that references the enrolled Subscriber’s Certificate Number. Each child is subject to underwriting.

To Delete Family Members

To delete a family member from a policy, Anthem Blue Cross must receive this request in writing. The request will become effective the first of the month following the request.

You may send your request to: Anthem Blue Cross P.O. Box 9051 Oxnard CA 93031-9051 Or you may fax the change to our membership department: 800-327-9255

If you have questions about whether a drug is on the prescription drug formulary or needs to be approved, please click here or call us at (800) 7002533.

Most people already have a strong preference between these two models but in case you a need a quick summary, here it is.

With a PPO, you have more flexibility to choose your doctors; you are not locked into a region or a primary care doctor.

You can self-refer yourself out to specialists.

The trade off is that you will help share the costs when you get sick or hurt in the form of a deductible or co-insurance.

With an HMO, you choose a Primary Care Physician who has more control over referral and/or decisions regarding your care.

You must remain within your medical group and within a geographic region.

The trade off with this more structured approach is that there will be less out of pocket when sick or hurt. For example, for inpatient hospital, you may be looking at nothing out of pocket.

TIP: HMO's have become more expensive so compare the annual premium difference with PPO options to make sure you are not paying too much.

Yes.  Insurance companies may look at smoking and drinking history when they decide whether to offer insurance. 

The following chart summarizes underwriting information that health insurance companies have filed with the Department of Insurance.

Downgrading is easy to do within the same kind of plan such as Share 500 to the Share 1500. Upgrading is possible if you are in good health as it is subject to underwriting. To change your Anthem Blue Cross health plan go to www.ChangeMyCoverage.com

There are a few options for payment with either carrier.

• Billing - bi-monthly, quarterly
• Credit Card - Blue Cross allows monthly, bi-monthly, quarterly credit card deduction
• Checking account auto-deduction - monthly deduction.

No. Although you can select a California health plan such as a Blue Cross of California plan or buy a policy that should cover most medical, hospital, surgical, and pharmaceutical bills, no single policy covers everything. Moreover, you may want to consider additional single-purpose policies like long-term care or disability income insurance. If you are over 65, you may want a Medicare supplement policy to fill in the gaps in Medicare coverage.

If you work for a company with 20 or more employees, your employer must offer you (through age 69) the same California health insurance coverage offered to younger employees. After you reach age 65, you may choose between Medicare and your company

No. The policy can be canceled or renewed (by payment) month to month.

Blue Cross has an online application which tends to process very quickly. Otherwise, you can fax your completed application and copy of check (or credit card section) to 800-569-1156 to start the process immediately. You would then mail the original if paying by check. The credit card option just requires the faxed copy.

A physical is not required...only the completed application and first months premium. Anthem Blue Cross may require a physical for applicants over the age of 55 who have not had one in the last two years.

There is no fee to apply. Only the initial month's premium is submitted with the application.

The first month's premium must be submitted with the application. This can be done with a check made out to the carrier or via credit card (for Blue Cross of California). If the application is not approved, this initial payment will be fully refunded.

There are two different scenarios. If the applicant is in good health and there isn't much the carrier wants to check into, we usually hear back in one to two weeks. If the volume of applications is running high in underwriting, the time frame can be longer. If the carrier wants further information on something listed in the application, they will request records directly from the doctor and this can delay the processing time. It usually adds another 2-4 weeks depending on how quickly the doctor responds back to the request.

Yes. With either carrier, you have a single child or multiple siblings on one plan if they are under the age of 18.

The rates can change by class (the entire state of California or county) or when you move up to a new age band (typically at 5 year increments such as age 35-39). Since Anthem Blue Cross is the part of the largest insurer in the nation you will experience lower rate increases and less often. Once approved, Anthem Blue Cross cannot change rates based on your medical health or claims.

Getting Approved When applying for coverage, Anthem Blue Cross will make their decision to approve/decline coverage and/or increase rates based on pre-existing conditions. You can find more information on qualifying for health insurance. They are mainly looking for current or ongoing situations. Anthem Blue Cross underwriters will also heavily weigh anything that is open-ended such as a doctor's request for a check up in the future which has not happened yet. Medication now weigh heavily because of the associated cost. You can run your situation by us first to see what the probable outcome might be. The carriers cannot exclude a certain condition from coverage in order to approve a person's coverage. Once Approved If you have not had coverage in the prior 63 days before your effective date, there is a 6 month waiting period for pre-existing conditions. This means they will not pay out for claims relating to pre-existing conditions until you have been on the plan for 6 months. If you have not lapsed coverage more than 62 days up to your new effective date, the carrier will take into account your prior coverage against a 6 month waiting period.

Depending on what your condition is and when it was diagnosed and treated, you can probably buy Anthem Blue Cross California health insurance. However, the Anthem Blue Cross may do one of three things:

• provide full protection but with a higher premium, as might be the case with a chronic disease, such as diabetes;
• modify the benefits to increase the deductible;
• exclude the specific medical problem from coverage, if it is a clearly defined condition, as long as the insurer abides by state and federal laws on exclusions.

There are many medical conditions that may cause an insurance company to automatically deny or not approve your application.  These may include the following:

• Health problems for which you have not seen a doctor;
• Health problems that a doctor cannot explain;
• Health problems for which you have not completed treatment.

An insurance company may also automatically deny your application for the health conditions below.  There may be other health conditions that are not on this list.

• AIDS;
• Pregnancy, pregnancy of your spouse or significant other, planned surrogacy or adoption in process;
• Cancer, under treatment;
• Sleep Apnea;
• Severe mental disorders, such as major depression, bipolar disorder, schizophrenia or psychopathic personalities;
• Heart disease;
• Renal failure or Kidney Dialysis;
• Diabetes with complications;
• Cirrhosis;
• Multiple Sclerosis;
• Muscular Dystrophy;
• Systemic Lupus Erythematous;
• History of transplant;
• Lymphedema;
• Current infertility treatment;
• Hepatitis;
• Hemochromatosis

Insurance companies may offer you insurance at a higher premium and/or limit the products or benefits you can purchase if you had a health problem in the past but you have recovered or you have been without symptoms for some time.  Insurance companies will also do this for minor health problems that you had in the past or may currently have.  Insurance companies argue that these conditions pose a risk that it will cost more for your health claims than if you were completely healthy.  Each application and insurance company is different.  An insurance company may charge a higher premium or limit the products offered for the health conditions below.  There may be other health conditions and time frames that are not on this list.

• Stroke, after 10 years with no reoccurring problems;
• Allergies, while testing is in process;
• Ear infections, controlled with medications;
• Lyme’s disease, without symptoms after one year;
• Breast Implants (non-silicone);
• Ringworm;
• Joint sprain or strain, recovered and no restrictions;
• Migraine headache, mild and infrequent with no emergency room visits;
• Mild depression.

Yes.  Insurance companies usually look at your height and weight when they decide to offer insurance.  They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese.  Some insurance companies use a measurement called the Body Mass Index (BMI) to decide.  If your BMI is above 39, most insurance companies will not offer you insurance.  If your BMI is 30-39, an insurance company may offer you insurance at a higher premium.  If you have health problems because of your weight, such as diabetes or heart disease, an insurance company may refuse to insure you, even if your BMI is under 30.

Prior authorization is required for:

• All inpatient Hospital and Skilled Nursing Facility stays (except inpatient Hospital stays for the delivery of a Child, Mental or Nervous Disorders and Substance Abuse, or mastectomy surgery, including the length of Hospital stays associated with mastectomy).
• Home health visits.
• All Organ and tissue transplants and peripheral stem replacement and similar procedures and Coronary Artery Bypass Surgery.
• All infusion therapy and related service in any setting
• The following diagnostic procedures wherever performed:
  • Magnetic Resonance Imaging (M.R.I.) of the spine only.
  • Computerized Axial Tomography (CAT Scan) of the spine only.
  • Positron Emission Tomography (PET Scan)
• The following specified surgical procedures wherever performed:
  • Septoplasty
  • Knee arthroscopy

You may be able to nominate him or her. Call our Customer Service number on your ID Card. If you utilize the services of a non-Participating Provider, your out-of-pocket expenses will be considerably higher than when you use a Participating Provider. You will be responsible for all charges in excess of what Anthem Blue Cross allows for that provider.

Receiving services from Anthem Blue Cross PPO Providers can substantially reduce your out-of-pocket costs. These lower costs are due to negotiated rates that Anthem Blue Cross PPO providers agree to accept instead of their typical fees, and generally, benefits paid for non-participating providers are more limited. You do not need to make payment for services, unless your plan has an office visit copay, when you receive care from Anthem Blue Cross PPO providers. Anthem Blue Cross PPO providers file claims to Anthem Blue Cross for our members, then bill you for remaining portion of their charges. You do not have to file a claim form for services rendered by Anthem Blue Cross PPO providers.

Anthem Blue Cross Individual Services issues ID cards with the subscribers name only. Dependents names are not listed.

Yes. Insurance companies usually look at your height and weight when they decide to offer insurance. They may offer you insurance at a higher premium rate or refuse to insure you if you are overweight or obese. Some insurance companies use a measurement called the Body Mass Index (BMI) to decide. If your BMI is above 39, most insurance companies will not offer you insurance. If your BMI is 30-39, an insurance company may offer you insurance at a higher premium. If you have health problems because of your weight, such as diabetes or heart disease, an insurance company may refuse to insure you, even if your BMI is under 30.

Anthem Blue Cross may offer you medical coverage at a higher premium and/or limit the products or benefits you can purchase if you had a health problem in the past but you have recovered or you have been without symptoms for some time.  Insurance companies will also do this for minor health problems that you had in the past or may currently have.  Insurance companies argue that these conditions pose a risk that it will cost more for your health claims than if you were completely healthy.  Each application and insurance company is different.  An insurance company may charge a higher premium or limit the products offered for the health conditions below.  There may be other health conditions and time frames that are not on this list.

• Stroke, after 10 years with no reoccurring problems;
• Allergies, while testing is in process;
• Ear infections, controlled with medications;
• Lyme’s disease, without symptoms after one year;
• Breast Implants (non-silicone);
• Ringworm;
• Joint sprain or strain, recovered and no restrictions;
• Migraine headache, mild and infrequent with no emergency room visits;
• Mild depression.

This basically lets you know how the plan will treat large bills...so called catastrophic or major medical coverage. Your max-out-of-pocket let's you how much you will pay up to for covered benefits, in-network in a calendar year. Usually, the max is per person up to two people maximum. The Blue Shield Preferred Savings plans have a family deductible for 2 or more people on one plan.

A deductible is an amount that you will pay first before the plan kicks in. Keep in mind that you will still get the discounted rate (usually 30-60% off) on covered benefits, in-network even before you meet your deductible. After the deductible is met, you typically go into a % of the discounted rate. Some benefits such as maternity and brand name descriptions will have their own, separate deductible.

Currently there are a few health plans that stand out as being good values. Interestingly enough, they are also the most popular plans state-wide. All these plans combine solid carrier strength and comprehensive coverage with a high(er) deductible which helps to keep your monthly rates down. With current rate increases (last four years), this this is a smart way to insure. Check out the following plans:

ClearProtection (no maturnity)
SmartSense (no maturnity)
CoraGuard (no maturnity)
Lumenos HIA
Lumenos HSA (no maturnity)
RightPlan40 (no maternity)
PPO 3500 HSA Compatible Plan
HMO Saver

There are a lot of differences between a PPO and an HMO, but the biggest differences are in how you access care, and what providers you can access. For more information and the differences see, Difference between HMO and PPO? and Whats is the difference between HMO, PPO and POS?

Your aim should be to insure yourself and your family against the most serious and financially disastrous losses that can result from an illness or accident. If you are offered health benefits at work, carefully review the plans