Anthem Blue Cross Blue Shield Market Individual Medical Insurance Plan Pre Existing Exclusion

Individual Health Insurance and States:  chronologies OF CHANGE

Country Reform Initiatives in Effect Before and During the ACA

Includes updates August 2015

Introduction: Individuals seeking private wellness insurance faced a number of challenges, peculiarly those whose employers do non offering any health insurance coverage.  Unlike near group insurance policies, acceptance for individual insurance was not guaranteed in near cases.  Applicants frequently were required to submit several years' worth of medical history earlier they are either canonical or denied insurance.  Furthermore, after the issuance of insurance, consumers might face up further difficulties.  For example, insurance companies had the flexibility in many jurisdictions to cancel health insurance retroactively, if they discover that the individual either knowingly or unknowingly omitted information about his or her wellness history in the application for insurance.  Retroactive cancelation requires the consumer to pay dorsum to the insurance company any funds the company may accept already covered for the consumer'southward wellness expenses.

At the start of 2010 it was estimated that there were 17-18 one thousand thousand people with individual coverage.  In light of increasing consumer and policymaker dissatisfaction with the individual market place choices, states had begun to legislate in the area of individual health insurance to protect consumer rights.  Until the launching of ACA Exchanges in Oct 2013, about lxxx% of individuals enrolled in non-group plans nationally were served by a Blue Cross Blue Shield licensee.

Federal Wellness Reform and the Individual Market

The 17 one thousand thousand people who are covered in the individual wellness insurance market, where switching of plans and substantial changes in coverage are common, have seen significant market changes because of the Affordable Intendance Act (ACA). Roughly 40 percent to ii-thirds of people in individual marketplace policies changed plans within a year. Individuals whose plan changes and are no longer grandfathered now gain access to free preventive services, less restrictions pertaining to annual limits, and patient protections such as improved admission to emergency rooms. These Americans also now have access to the Health Insurance Exchanges that provide coverage as of 2014, to offer individuals and workers in pocket-sized businesses a much greater choice of plans and with a goal of more than affordable rates.

2015 Study: Comparison ACA's Private Insurance Market Reforms

Early predictions that wellness plans sold through the Affordable Care Act's insurance marketplaces would attract a higher share of people with plush wellness bug take not been realized, an Baronial 2015 Commonwealth Fund study finds.  To see whether the ACA's reforms of the private marketplace are working to promote competition based on value instead of insurers' ability to segment consumers based on their health run a risk, researchers compared plans sold on and off the exchanges. They found that plans featuring more generous benefits, which appeal to people with health bug, are more than unremarkably sold off the exchanges rather than on. Projected administrative costs and profit margins are higher for insurers operating outside the marketplaces—"a testament to the exchanges' ability to sell coverage efficiently," the researchers say. [ Read full brief 10pp - PDF] The Commonwealth Fund , 8/18/2015.

Federal Health Reform and the Individual Market, Background 2008 to 2013

• "Essential Health Benefits: Private Market Coverage"

  The Affordable Intendance Act designated 10 categories of services and items included in essential health benefits (EHBs). The x categories include: ambulatory patient services; emergency services; hospitalization; maternity and newborn intendance; mental health and substance utilize disorder services, including behavioral health handling; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic affliction management; and pediatric services, including oral and vision care.

All ten categories of services and items must exist covered by insurance offered in the individual and small group markets as of January 1, 2014.¹
According to data on pre-ACA marketed plans submitted by wellness insurance companies to HealthCare.gov, many individuals and families who purchased their own health insurance did not have coverage for several of the categories of benefits now included in EHBs. ²

• 62 percent of enrollees did not have coverage for maternity services.
• 34 percentage of enrollees did non accept coverage for substance abuse services.
• 18 pct of enrollees did not have coverage for mental health services.
• 9 percent of enrollees did not have coverage for prescription drugs.

Americans who bought coverage in the private marketplace starting in 2014 gained access to these required essential health benefits. Based on 2013 estimates of the size of the individual market³ and the per centum of enrollees in currently marketed plans without coverage for certain services, coverage of benefits in the private market may aggrandize as follows:four

• 8.vii million Americans volition gain maternity coverage.
• 4.viii million Americans will gain substance abuse coverage at parity with medical and surgical benefits.
• two.3 million Americans will gain mental health coverage at parity with medical and surgical benefits.
• 1.three million Americans will proceeds prescription drug coverage.

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State Protections for Treatment of Pre-Existing Weather condition for Individual Markets

Land law changes and regulation of the small group health insurance market have been heavily influenced by the passage of The Health Insurance Portability and Accountability Deed of 1996 (HIPAA). This federal law was designed to increase the access, portability and renewability of individual health insurance by setting minimum standards that utilise to the individual, small grouping (including fully insured and self-insured) and large group markets of all states.All l states now take some type of land statutory protection and/or definitions related to coverage (or exclusion) of pre-existing weather.  A much shorter list of states have no waiting period or "expect-back" period.  In the absence of a waiting period or "look-back" period stipulation, insurance companies tin can not deny individual wellness insurance on the basis of pre-existing conditions.

Individual Market Reforms

Since the individual market was previously non highly regulated, the federal standards afflicted insurers selling individual policy in several states, specially those with laws dated afterward 1996.  Individual reforms have iii significant differences from the reforms targeting small groups:  1) pre-existing condition exclusion clauses are not allowed; in particular, issuers may not impose pre-existing status exclusions upon individuals eligible for group-to-individual guaranteed access.  2) a country may opt out of the guaranteed event provision with "acceptable" culling mechanisms;  and 3) eligibility requirements exist (guaranteed renewal applies to all of those in the individual market place, not only HIPAA eligibles).

Health Insurance Exchanges

Between 2007 and 2010, two states launched wellness Insurance Exchanges, or "Connectors" aimed at aiding those who rely on the individual market. Individuals volition have increased ability to utilize Health Insurance Exchanges with the implementation of federal wellness reform. See details on Massachusetts, Utah and Florida in NCSL's study:  Health Insurance Exchanges: Overview and Land Actions - PDF File (November 2009)

Consumer Assistance Programs (CAP)

For more than a decade at to the lowest degree 20 states offered various types of consumer aid programs for those having questions or difficulty in maintaining or obtaining wellness insurance.  With the passage and implementation of the ACA, the role of these programs has become more prominent.  Federal ACA grants to states provided new impetus for such programs, but the electric current landscape varies by states.

• On online study by CCIIO within HHS provides a federal perspective on this land surface area of action. Run across: http://www.cms.gov/CCIIO/Resources/Consumer-Help-Grants/
• CAP in Operation, Recognized by HHS:
  1. Akansas (AR)
  2. California (CA)
  3. Connecticut (CT)
  4. District of Columbia (DC)
  5. Georgia (GA)
  6. Illinois (IL)
  7. Kansas (KS)
  8. Maine (ME)
  9. Maryland (Doc)
  10. Massachusetts (MA)
  11. Michigan (MI)
  12. Mississippi (MS)
  13. Missouri (MO)
  14. Nevada (NV)
  15. New Mexico (NM)
  16. New York (NY)
  17. N Carolina (NC)
  18. Oklahoma (OK)
  19. Oregon (OR)
  20. Pennsylvania (PA)
  21. Rhode Island (RI)
  22. Vermont (VT)
  23. Virgin Islands (VI)

Archive and Legislative History: Before ACA Implementation 2000-2010

Use only for comparison to new data, 2010-2016

Table Definitions:
The following definitions and abbreviations utilise to the tabular array below:

Guaranteed Result:  Requires insurance carriers to offer coverage regardless of claims history or wellness status.

Preexisting Conditions:  Limits the amount of time a carrier can exclude coverage for a condition that was present before the new coverage began.  As well usually limits the amount of time a carrier can "wait dorsum" to consider a condition equally preexisting. The tables list two numbers indicating first, the maximum exclusion time in months, and second, the look-back fourth dimension in months (i.eastward., 12/6). Look-dorsum provisions often use one of 2 specific standards and definitions:

• "Prudent Person" definition, pregnant that the average layperson would have sought treatment or communication for the given condition.  This means that actually consulting a health care provider is not e'er necessary for a condition to be considered preexisting.
• "Objective Standard" definition, which includes those conditions for which someone actually received medical advice, diagnosis, care or treatment prior to enrollment to be counted as pre-existing. A portability provision commonly is included so that a waiting period served nether a previous policy is credited toward the new policy.

Guaranteed Renewal:  Requires carriers to renew policies with small groups or individuals regardless of claims experience. Insurers may discontinue coverage only if the individual or business organization is at fault (e.yard., failure to pay premiums, fraud). Annotation that the federal HIPAA legislation requires guaranteed renewal.  Each state enforces HIPAA requirements with the Centers for Medicare and Medicaid services (CMS) playing an enforcement role under certain weather.  If a state notifies CMS that it has not enacted legislation to enforce or that it is not enforcing HIPAA requirments, so CMS becomes responsible for that function.The table beneath includes laws on the specific topics current to December 2008.

Land	GUARANTEED Issue	GUARANTEED RENEWAL	PRE-EXISTING Weather	DEFINITION OF PRE-EXISTING Atmospheric condition
AL	No	HIPAA	Yes (24/lx)	No Definition
AK	No	HIPAA	Yes (no limit/no limit)	No Definition
AZ	No	Chap 251-431R (SB 1321, 1997)	Aye (no limit/no limit)	No Definition
AR	No	HIPAA	Yeah (no limit/threescore)	Prudent Person Standard
CA	Partial1	1997	Aye, 1993 (12/12)	Objective Standard
CO	No	1996, 1997	Yep (12/12)	Objective Standard
CT	No	1997	Yes, 1993, 1997, 20081 (12/12)	Objective Standard
DE	No	SB 166 (1997)	Yes (no limit/60)	Prudent Person Standard
FL	No	1996, 1997	Yep 1996 (24/24)	Prudent Person Standard
GA	No	1995, 1997	Yes (24/no limit)	No Definition
HI	No	1997	Aye (36/no limit)	No Definition
ID	Partial2, 1994, 1995	1994, 1997	Aye, 1994 (12/6)	Prudent Person Standard
IL	No	1997	Yes (24/24)	Prudent Person Standard or Objective Standard
IN	No	1998	Yes, 1995, 1996 (120/12)	Prudent Person Standard
IA	Partialiii, 1995	1995, 1997	Yes, 1995, 20082, 2010 (24/sixty)	Prudent Person Standard
KS	No	1997	Yep (24/no Limit)	No Definition
KY	Partial4,1994, 1998	1998	Yes, 1994 (6/six), 1996 (12/six)	Objective Standard
LA	No	1993, 1997	Yes, 1995, 2010 (no limit/12)	Prudent Person Standard
ME	Yes, 1993	1993, 1997	Yes, 1993 (12/12)	Prudent Person Standard
Doctor	No	1997	Yeah, 2010 (12/12)	Objective Standard
MA	Yes, 1996	HIPAA	Yeah, 1996, 2006 (half dozen/6)*	Objective Standard
MI	Fractional5	HB 5571 (1996)	Yep, 1996 (12/six)**	Objective Standard
MN	No	1992	Yes (18/6)	Objective Standard
MS	No	1997	Yes, 1997 (12/12)	Prudent Person Standard
MO	No	HIPAA	Yep (no limit/no limit)	No Definition
MT	No	1997	Yes, 1995 (12/36)	Objective Standard
NE	No	1997	Yes (no limit/no limit)	Prudent Person Standard
NV	No	1997	Yes (no limit/no limit), 2010 (no limit/half-dozen)	Objective Standard
NH	Partial6, 1994	1994, 1998	Yes, 1994 (9/iii)	Objective Standard
NJ	Yes, 1992	1992, 1997	Yes, 1997 (12/six)	Prudent Person Standard
NM	No	1998	Yes, 1994 (half-dozen/6)	Prudent Person Standard
NY	Yep, 1992	1992, 1997	Yes, 1992 (12/6), 1997	Objective Standard
NC	No	1997	Yep (12/12)	Objective Standard
ND	No	1995, 1997	Yep, 1995 (12/half-dozen)	Objective Standard
OH	Partial7,1993 (capped enrollment)	1993, 1997	Yes, 1993 (12/6)	Prudent Person Standard
OK	No	HIPAA	Yeah (no limit/no limit)	No Definition
OR	Partial8	1995, 1997	Yep (24/6), 2010 (six/6)	Objective Standard
PA	No	1997	Yes (12/threescore)	Objective Standard
RI	Partial9	1995	Yes (12/36)	Prudent Person Standard
SC	No	1997	Yes (24/no limit)	Prudent Person Standard
SD	Partial10,1996	1997	Yes, 1996 (12/12), 1997	Prudent Person Standard
TN	No	1997	Aye (24/no limit)	No Definition
TX	No	1997	Yes (24/60)	Prudent Person Standard
UT	Fractional11, 1995	1995, 1997	Aye, 1995 (12/six)	Objective Standard
VT	Yes, 1992	1997	Yes,1992, 1997 (12/12), 2006	Prudent Person Standard
VA	Partial, 1998	1996, 1997	Aye, 1995 (12/12)	Prudent Person Standard
WA	Partial12, 1993	1993, 1995	Yes (nine/6)	Prudent Person Standard
WV	Partial13	1995, 1997	Yes (12/24)	Prudent Person Standard
WI	No	1997	Yes (24/no limit)	Prudent Person Standard
WY	No	1995	Yep, 1995 (12/vi)	Objective Standard
Full STATES	nineteen	50	50	Objective Standard = 19 states Prudent Person Standard = 24 states

Source: Kaiser Family Foundation, State Health Facts, "Individual Market place Portability Rules (Not Applicable to HIPAA Eligible Individuals), 2010"

Footnotes for Guaranteed Consequence: Note: Details and updated data provided by "Wellness Policy Institute, Georgetown Academy" as published by Kaiser Country Health Facts- December 2007.

1. California: Insurers for the private markets and HMOs must guarantee issue a standardized policy to those exhausting High Hazard Puddle coverage (36 months).
2. Idaho: Private market insurers must guarantee issue standardized policies to the medically uninsurable. Insurers must offer basic, standard and catastrophic policies. These policies are called High Hazard Puddle Policies.
3. Iowa: Iowa provides a loftier run a risk puddle for those who cannot afford coverage in the private markets. The Iowa Individual Health Benefit Reinsurance Clan (IHBRA) has been merged into HIPIOWA effective Jan, 2005.
4. Kentucky: Beginning in 1998 with HB 315, the standardized plans and guaranteed issue requirements were replaced by a circuitous "pay or play" system that was named the Guaranteed Acceptance Plan. In 2000, HB 517 created a loftier hazard pool called the Kentucky Access. These measures were specifically taken to encourage more than people to return to the private markets.
5. Michigan: HMOs, after 24 months in existence, are required to guarantee result to a limited number of applicants during one, thirty day open enrollment per year.
vi. New Hampshire: There were many flaws with the 1994 police on guarantee issue. The greatest conflict beingness that the law did not crave individual policies issued before the law to comply with the new laws. Therefore, the impact of the reforms were dampened. Due to declining enrollments, the guaranteed issue was repealed in 2002. Instead, a high risk puddle was created.
7. Ohio: Individual market insurers must guarantee consequence standardized policies on a periodic ground. Non-HMOs are required to guarantee effect standardized policies (up to a limited number adamant of enrollees as determined by the state) for one 30 day menstruation, annually. HMOs are required to guarantee issue standardized policies annually until reaching a country determined limited number. For HMOs, this flow could extend across thirty days.
8. Oregon: Private market place insurers must guaranteed result portability policies to individuals with 6 months of prior coverage.
nine. Rhode Island: Individual market insurers must guarantee upshot all products to those with 12 months of continuous creditable coverage, provided the applicant is non eligible for alternative group coverage, Medicare or any other state health insurance plan.
x. South Dakota : The South Dakota Take a chance Pool was created in 2003 to provide coverage to people who accept lost coverage and take previous creditable coverage. However, unlike most loftier-risk pools, the program does not serve uninsured individuals who take a pre-existing condition or disease that causes them to be declined by private insurers unless the person recently lost creditable coverage.
11. Utah: Individual market insurers that accept not met enrollment cap must guarantee issue at to the lowest degree one individual market policy to those that are otherwise not eligible for any other type of health insurance coverage (i.e group, HRP, etc.).
12. Washington: The insurers must guarantee issue all products to their applicants,  who receive a minimum score on the state mandated health status questionnaire. The applicants that are not eligible for guarantee consequence are referred to the high risk pool.
13. West Virginia: HMOs with greater than five years in the market place or with enrollment not less than 50,000 must guarantee consequence during the annual thirty day open enrollment period.

Footnotes for Pre-Existing Weather:* Cannot be applied to guaranteed issue products.**Commercial insurers: 6/12, BCBSMI and HMOs: 6/6

i. Connecticut:

• Hr 2833: The legislation would permit insurers to look back only a period of 30 days on medical records of applicants. Furthermore, the legislation extends the HIPAA protections to individuals who are insured through employer-based private plans and non-grouping, private plans.
• Charter Oak Plan: The plan would require managed care companies to provide health coverage to residents who have been uninsured for at to the lowest degree six months and are ineligible for publicly funded health programme and charge only the premium.

2. Iowa: The HF2539 legislation would prevent private insurance companies from using preexisting health weather confronting its applicants.

Brief Legislative History of Private Insurance Reform

Before HIPAA was enacted, there was significantly less regulation of the individual market. S Carolina took the commencement steps in 1991 by enacting portability and rating bands. Since then, 14 states enacted guaranteed issue laws (with the almost recent police passed in 1998 in Virginia), 42 required guaranteed renewal (which HIPAA requires), 30 placed limits on preexisting condition exclusion clauses and 18 have rating restrictions.

2007-08 STATE Actions: Prompted past numerous consumer complaints and lawsuits confronting insurers, state lawmakers took action. Among their efforts:

New Mexico: The Legislature passed bills requiring insurers to show that applicants deliberately gave wrong information on an application. Current law allows cancellation if the mistake or omission was inadvertent. Without the law, "the consumer has no ability to defend" confronting a cancellation, says Melinda Silver, attorney with the state's Managed Health Care Bureau. (SB 226 Signed into police every bit Chapter 87, 3/iv/08)

Connecticut: In October 2007, a new law took effect requiring approval from the state insurance commissioner before an insurer could abolish an existing policy.

California: California land regulators announced counterfoil-related fines confronting some insurers, including Blue Cross, Kaiser Permanente and Blue Shield of California.  Legislation introduced in February 2008 required insurers who wanted to cancel a policy to offset win approval from the state's Department of Managed Health Intendance. Legislators adopted a law requiring insurers to pay for whatsoever medical treatment they corroborate, even if they afterwards cancel the policy.

Washington: In March 2008, the Washington state legislature enacted SB 5261, which was signed into constabulary the following month by the governor.  This legislation restores state oversight of the individual health insurance market place.  Specifically, the law authorizes the Insurance Commissioner to disapprove unreasonable rate increases and establishes a sliding-calibration medical loss ratio for insurers (Medical loss ratios require insurers to spend a certain amount of premium revenue on straight medical intendance.  These laws help ensure more of the premiums are used on medical care and less on administrative costs, including profits and bonuses).

Sources: Tabl due east updated Baronial 2006 and June  2008 by the NCSL Health Program; selected text adopted from a longer issue cursory on HIPAA, originally published 10/three/00 by Health Policy Tracking Service and updated in 2003.  Data too has been compared to online material by Kaiser Family Foundation, at http://www.statehealthfacts.org/comparetable.jsp?ind=353&true cat=vii or http://world wide web.statehealthfacts.org/.

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Land Action Pertaining to Guaranteed Issue: Pre-Existing Condition Coverage

Although all 50 states have some regulations on preexisting conditions, currently, five states have laws that ban insurance companies from rejecting insurance coverage for applicants on the basis of preexisting conditions. The legislation requires insurers to sell coverage to all applicants regardless of their past medical history.  This concept is too known equally guaranteed issue.  Since many insurance companies consider caesarean section and even pregnancies equally preexisting conditions, the insurance companies in these five states would cover the expenses, without futurity repercussions to the mother. The policies in the post-obit states are Modified Community Rated, which guarantees insurance applicants will not exist denied coverage or affect insurance rates due to pre-existing conditions, as long as the applicant has previously maintained continuous coverage.

STATE	DETAILS
ME Title 24-A Chiliad.R.S.A. §§ 2736-C and 2808-B	Requires an insurer to make available to all individuals any individual policy beingness marketed to Maine residents.  A carrier may deny coverage to individuals if the carrier has demonstrated to the Superintendent'southward satisfaction that the carrier does non have the chapters to deliver services adequately to additional enrollees within all or office of its service area because of its obligations to existing enrollees.
MA Chapter 58 of the Acts of 2006	Pre-existing condition is defined as "a condition present before the date of enrollment for the coverage, whether or not whatever medical advice, diagnosis, care or handling was recommended or received before that date. Genetic information shall not exist treated as a status in the absenteeism of a diagnosis of the condition related to that information."  Carriers cannot exclude applicants for insurance on the basis on the definition of pre-existing condition every bit divers above.
NJ South 1870	S 1870 is an addition to the innovation health insurance police that was enacted in 1992 that "provided guaranteed-event, guaranteed-renewal coverage, with a prohibition against rating on the basis of health status and limiting preexisting condition exclusions in policies".
NY A 02609	No pre-existing condition provision shall exclude coverage for a period  in  backlog  of  twelve  months following the enrollment date for the covered person and may only relate to a condition (whether  physical  or mental),  regardless  of  the  crusade  of the condition for which medical advice, diagnosis, intendance or handling was recommended or received  within the  six  month  menstruum  ending on the enrollment date.
VT § 8086	No long-term care insurance policy or certificate may exclude coverage for a loss or confinement which is the result of a preexisting status, unless such loss or solitude begins inside half dozen months following the constructive date of coverage of an insured person.

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Gender Distinction in Individual Insurance Rates

Insurance carriers are able to accuse men and women different premiums for individual insurance nether a do known as gender rating in 38 states.  Eleven states - Colorado, Washington, Oregon, Montana, Northward Dakota, Minnesota, Massachusetts, Connecticut, New Hampshire, Maine, and New Jersey have protections confronting the employ of gender to set premiums in the private health insurance marketplace.  Two other states - New Mexico and Vermont limit the use of gender to set premiums in the individual health insurance market with a rate ring.  Gender rating has been criticized for creating financial barriers for women seeking to obtain health insurance.  On the other hand, gender rating has been defended on the basis that it is actuarially justifiable - that women have higher cost health expenses than men and therefore premiums reflect that difference in costs to providing health care to men and women generally.  In whatsoever case, many states that allow gender rating crave that whatsoever divergence in premium rates for men and women be "justified by actuarial statistics".  Thus, these states crave proof of bodily differences in toll of providing wellness care to women and men by and large for insurance carriers to use gender rating.

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Additional Resources

NCSL ONLINE RESOURCES

• Wellness Insurance and the States, NCSL online publication.
• Wellness Insurance Exchanges: Overview and Land Actions - PDF File (November 2009)
• State Legislation and Deportment on Wellness Savings Accounts (HSAs) and Consumer Directed Health Plans, 2004-2010.

Non-NCSL ONLINE Resources

• Individual Market Charge per unit Restrictions past State, 2007.  Kaiser State Health Facts.
• Individual Health Insurance 2009: A Comprehensive Survey of Premiums, Availability, and Benefits.(October 2009)  AHIP Center for Policy and Research.
• Nowhere to Plow: How the Private Health Insurance Marketplace Fails Women.  National Women'south Law Center. (2008)

Additional EXPERT Resource AND OPINIONS

• Monheit, Alan et al (2004) "Community Rating and Sustainable Individual Health Insurance Markets in New Jersey,"  Health Diplomacy, vol. 23, number 4, pp. 167-175.
• For a critical assessment of country consumer protections see: "Failing Grades: State Consumer Protections in the Individual Health Intendance Market,"  Families USA (2008).

MEDIA ARTICLES

• "Gender Gap Persists as Health Insurers Resist Adopting Police Early," Robert Pear, New York Times, 3/19/2012
• "States Human activity to Protect Individual Health Coverage," Julie Appleby, USA Today, two/21/08.
• "Shifting Careers: Finding Health Insurance if you lot are Cocky-Employed," Marci Alboher, New York Times, 3/27/08.
• "Premera surpluses here subsidize Arizona losses,"  Brian Slodysko,  Seattle Post-Intelligencer, 2/24/08. Article publicizing insurer profits and the push for individual marketplace reform in WA state.
• "Women buying health policies pay a penalty," Robert Pear, New York Times, 10/28/08.

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Source: https://www.ncsl.org/research/health/individual-health-insurance-in-the-states.aspx

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