individual health insurance maternity coverage
individual health insurance maternity coverage
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Individual Health Insurance In Texas – Understanding Pre-Existing Conditions
Premiums for individual health insurance in Texas can be higher and overall coverage limited by pre-existing conditions. When a person applies for a policy, insurers interview the candidate to asses her current overall health status as well as conditions or treatments for which she has sought treatment in the past, such as depression, fibromyalgia or diabetes. The insurer may opt to offer a policy with an elimination rider to exclude coverage for certain pre-existing conditions for up to 24 months, sometimes longer.
When a person with individual health insurance in Texas submits a claim, the insurer may investigate whether she has sought treatment for the same condition within the past five years. Even if no such pre-existing condition was discovered before the policy was issued, the insurer can deny coverage of the claim or even take steps to declare the coverage null and void. HIPAA – the Health Insurance Portability and Accountability Act – was passed in 1996 to protect people and their families from losing coverage when they change or lose their jobs and limits the use of pre-existing condition restrictions by insurers. Under HIPAA, maternity benefits cannot be denied.
Only those illnesses and conditions that are actually present in a policy holder’s current health or health history is subject to pre-existing condition limits. Genetic information cannot be used to deny coverage or charge higher premiums for individual health insurance in Texas as it is only an indication of a person’s predisposition to certain illnesses and is not evidence of those conditions being present. Pre-existing condition riders are not allowed by law at HMOs in Texas. Per HIPAA, pre-existing conditions will not apply if the policy holder has had some form of continuous group coverage for at least 18 months with no gaps longer than 63 days.
Health insurance policies have guaranteed renewability, meaning they cannot be canceled, so long as the holder pays the premiums and adheres to all other premium guidelines, including any residency requirements. So-called temporary health insurance policies that provide coverage for a limited short period of time (i.e. six months) are not guaranteed renewable. The most cost-effective option for a person seeking individual health insurance in Texas is by joining a group health plan through an employer due to federal requirements related to your employer paying a larger portion of the employees’ premium. These group plans do become costly when an employee adds dependents to the policy as there are no mandates requiring you employer to pay any portion of their premium. Also church, union or association, such as a Chamber of Commerce or other professional organization may also offer coverage, generally at a higher rate than individual policies. Individual health policies are generally far less expensive than group plans due to federal requirements on group plans related to guaranteed issues provisions and other federal mandates.
Overall, if you have major health conditions it is advised to get coverage from your employer as group policies require guaranteed issue. But if you are free of major health conditions you can get an individual health insurance in Texas policy at a much lower rate in most cases.
About the Author
Charles Peeler has been providing Individual Health Insurance in Texas since 1993. For more information or to acquire a quote he recommends this Texas Health Insurance site.
Why doesn’t my health care provider have to give me in-network prices for treatments not covered?
My wife is pregnant with our 2nd child and our individual health insurance doesn’t cover maternity. I am self-employed and have no access to group health, and it’s literally impossible to get maternity coverage on your own. Anyways, I asked for a quote from her OBGYN for the whole package, and was given a self-pay price. I asked about the in-network price (Blue Cross Blue Shield Texas PPO) and was told that I am not getting an in-network discount because it’s not a covered benefit. I called my insurance and they said it’s up to my provider to give me a discount or not.
I am confused, I thought that was the whole point of having provider networks, because you get discounts. If it’s a covered benefit or not is between me and my insurance and shouldn’t be a concern for my doctor, right? Shouldn’t he just give me the in-network price on everything?
why give you a discount for services not covered? they are quoting prices anyone without insurance will pay. if you expect your insurance to pay for a covered service, of course its a concern for the provider.
no, you should not get the in network price on services that are not covered. that makes no sense.
