California health insurance  -  Individual California heatlh insurance  -  How do pre-existing conditions affect underwriting

How do pre-existing conditions affect my California health insurance options?

IMPORTANT UPDATE:  Underwriting is no longer required for ACA health plans.


Pre-existing conditions do not factor into enrollment.

You can quote the new Guaranteed Issue plans including Covered Ca here

Every one has a health history.


Yes, we occasionally receive a completely clean application where there is not much present or past but that's not the fact it's the odd one out in today's world.


If you're shopping for California health insurance and you have a human body, there's probably going to be a health history and even current pre-existing conditions going on.


How does this affect your options and most importantly, your health insurance rates?


Great question so let's dive into pre-existing conditions.


You can always run your quote here:

how to quote Covered California plans

Rate Tiers Based On Health


First, let's understand how the carriers react to different levels of health conditions.


The quotes you see when running your California individual health insurance quote are the best rates available...period.


These rates are based on good health or what the California health carriers call "Tier 1".


Your "tier" is locked in at the time of underwriting based on your health status/history and does not change if your health changes during the life of the health policy aside from potentially getting better which we'll discuss later.


The carriers can then go up tiers based on health pre-existing conditions.


Tier 2 is generally 25% higher than the Tier 1 Rates. here is a special 20% increase (not a tier change) due to smoking or tobacco usage.


Things start to go up pretty quickly beyond Tier 2.


Tier 3 can be 75%-100% higher and by the time you get to a Tier 5, you're looking at almost 300% higher. We rarely see Tier 5 because after all, it's almost an insult.


Since 3/23/2010, Health Reform has mandated that children will be guaranteed issue which means that they cannot be declined coverage due to health.


This is a precursor to what will occur Jan 1st, 2014 for the rest of the pre-65 population.


On one hand, children cannot be declined coverage based on pre-existing conditions but the tier increase can be very high depending on their health status.


We can also see split tiers for a family applying for coverage.


For example, one parent may have Tier 1 rates (best rates) while the spouse is offered a Tier 2.


Children may also have different tiers based on health but they are guaranteed issue which brings us to our second concern with pre-existing conditions for adults.

What percentage of Californian applicants get declined?


A California carrier currently can decline coverage based on his or her health status and history.


There's a tendency of people we speak with to assume that any small health issue will automatically result in a declination.


We actually get quite a bit approved (estimated about 70-80% of applications are approved) with a wide array of health histories and pre-existing conditions.


It's not impossible to list in one article all the varying issues and results but let's spell out some general guidelines.


Of course, we're happy to walk through your particular situation to offer guidance on what might be expected which is always the best approach since we have decades of real experience with underwriting.


You can access the online application here:

How to apply for California obamacare


Let's look at the guidelines.


1.     If there's some follow up or treatment prescribed but not had yet, the carriers will likely not offer coverage until this is completed.


It can be a surgery or as benign as a final follow up or lab.


Either way, the carrier will want to see this completed if the doctor/provider has requested it.


Many times a doctor will list a follow up and the patient's not even aware it's there in the records.


This is pretty common.


2. For maintenance medications (cholesterol, blood pressure, etc),


the carriers generally look at monthly cost, how long it has been used (stability), and whether it's been effective.


If a medication is new, they can't judge exposure since the prescription may change if it is not effective.


Multiple medications can pose a problem because there are that many more chances of an expensive brand name drug being substituted.


3. The time away from a given health issue is important


If you broke a bone last month, we will likely not be able to get approved. However, if we have 6 months away from a simple break, that's a different story altogether.


The longer away from a situation being resolved (sign, symptom, and most importantly...treatment free), the better our chances of qualifying at the best rates.


A declination now doesn't mean one forever and does not impact your future chances as the time away changes our potential outcome.


People's health situations are complex so it's best to discuss it with us.


We will give you the best guidance possible on what you might expect from underwriting.


There are options for people who have been declined coverage such as PCIP (without coverage for past 6 months) or MRMIP assuming you do not have a Cobra option .


If you do get a higher tier rating, we may be able to reduce in the future (minimum of 3 to 6 months depending on situation) and there's nothing like better than reducing these tier increases.


Things are scheduled to change Jan 2014 with guaranteed issue coverage albeit at higher overall costs and we'll adjust accordingly.


Until then, you have a blue print above on how the carrier will view pre-existing conditions.


Contact us to fill in the details.


Call us at 800-320-6269 with any questions.  Our services are free to you as licensed health agents.


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