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California health insurance  -  Individual and Family health  -  Insurable for health coverage

Qualifying for Individual California Health Coverage

IMPORTANT UPDATE:  The new ACA health plans are not medically underwritten.  You can quote the new health plans including Covered Ca here.

Individual and Family medical insurance is different from Group (Company) insurance in that they can decline and or change rates based on your medical 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.

Reasons for Declination

Some health issues and reasons for declination are time sensitive. This means that we may be able to qualify at a later time with more time from when a health issue is sign, symptom, and treatment free. For very basic situations, we generally need 3-6 months away. More involved situations might require 12-18 months and serious issues such as certain kinds of cancer can require years away.
There are multiple carriers on the California health market and although their underwriting guidelines are similar, they do fluctuate. This means that we may get a declination from one carrier and an approval from another. Based on experience (2 decades now), it appears that if claims spike, underwriting tightens so there can be applicants where we expect a decline but get an approval and vice versa. For questionable health situations, it makes sense to apply to two carriers at the same time since you have a 10 day free look window when they come back with a decision. This makes sense when time is critical (such as being in the Cobra election period).
Let's look at medication costs which can definitely affect our ability to qualify for coverage. First, a newer prescription can be more concerning. If you have been on a prescription for a longer period of time (let's say 6+ months), the carriers can then evaluate your application based on monthly cost. This is how carriers will look at maintenance medications (for example, cholesterol or blood pressure). What is the monthly cost? Brand name medications obviously affect this analysis quite a bit since they are much more expensive. A generic equivalent will weigh less heavy on the underwriting decision. Keep in mind that a sudden switch to generic (or plan to) will not help us qualify since it falls under the "newer prescription" issue above.

Cobra continuation coverage

A Cobra option can affect what we want to do regardless of underwriting. Cobra is generally very expensive but it's guaranteed issue (regardless of health). We just want to make sure we don't lapse our Cobra election option or monthly payment while applying for individual health insurance. We have written an entire article on the Cobra versus Individual California health insurance option.
California health carriers can offer split decisions. They may approve one family member and decline another. There's an "all or none" question on the application which we recommend not checking. It's best to let the carriers underwrite individually for family members and see what they come back with.
Carriers are generally looking at recent or more serious health history situations. We all have health issues and yet 80% of applications get approved so it's best to apply and see what the come back with. Children will be guaranteed issue now anyway.
If you have not had coverage for the last 6 months, you may be eligible for the PCIP plan. We still need a declination to qualify so we want to apply for standard coverage (ideally our preferred plan) either way.
If you have questions about your preexisting conditions whether listed above or not, please call us at 800/320-6269 or email us to receive personal assistance from a licensed California medical agent. We will be able to advise you based on your specific medical history.


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