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Arizona Policy Restrictions

In the state of Arizona all health insurance policies are mandated by law to cover newborns and even adopted under Michelle’s Law for the first 31 days if the family is covered as well.  The insured is required to make certain the new child is covered after this period.

Like the rest of America all health insurance policies are guaranteed renewable but an insurance company may terminate a policy if there has been any fraudulent information included in the application. Therefore, it pays to be honest when you fill out your application.

Arizona also must follow the regulations of the Affordable Care Act, including access to insurance for all Arizonans regardless of health status, premium rating based on nondiscriminatory factors, and subsidized coverage for low-to-moderate income residents through the marketplace.


Arizona Insurance Company Restrictions

One of the laws that is unique to Arizona is that the health insurance companies are not mandated in their coverage by the state, so the health insurance companies can design their plans to be as profitable as possible under the laws of supply and demand.  Thus it becomes very important to review every health insurance plan before purchasing it, as one company might have very subtle differences from another.  For instance, emergency room copays,  the only health insurance company in Arizona that does not lump the emergency room towards the deductible and coinsurance is HealthNet and one or two of the Blue Cross policies.  For clarification on this you are encouraged to call us at 888 803 5917 so we can outline the differences and pick the best plan for you.

On the other side of this coin, is that the health insurance companies all had different pre-existing clauses before health reform. This is no longer an issue as the Affordable Care Act created an opportunity for all applicants to gain coverage regardless of their conditions. Companies cannot decline anyone coverage or increase their rates due to a health problem, nor can they eliminate the entire condition by ridering it out entirely or for a set period of time. Before this law, carriers could sometimes rider a condition and even charge you additional premium for a condition that isn’t even covered! The ACA opens the door to coverage for everyone regardless of their health, gender, occupation, or coverage gaps experienced.

Arizona plans are regulated by the federal health law, which requires insurers to include certain benefits in health plans so that residents can purchase “minimum essential coverage” and avoid the individual mandate penalty tax. This includes essential health benefits, which cover ten different categories of services in comprehensive plans sold on and off the exchange.

East Coast Health Insurance is very much anti-short term health insurance policies, due to the fact that a condition might materialize during this short time period and if it ruins your insurable interest or makes you uninsurable you will be forever without individual health insurance. Apparently, Arizona agrees with us and they have been mandated to not offer this type of coverage.  Thus there are no short term policies in Arizona, which is a law we think that should be extended into other states.  It comes down to the fact that these plans are not guaranteed renewable. Under the health reform law, having a gap in coverage should not leave anyone uninsurable, however.


Quick Law Outlines

Important Health Insurance Rights:
Appeals: You have the right to appeal an insurer’s denial of services or claim payments for 2 years after the denial.

Provider Timely Pay: Healthcare providers have the right to timely claim payments and to contest denied claim payments.

Employee Eligibility: Employers determine employee eligibility for health insurance…not the insurer. A.R.S. § 20-2307.

Small Group Policies: All group health insurers MUST write policies for small groups (2-50 employees) and cannot refuse to insure individual employees due to health condition. A.R.S. §§ 20-2304 and 20-2307.

Portability: If you lose your group health insurance coverage (after having at least 18 months of continuous coverage) you are GUARANTEED the offer of an individual health insurance policy with ANY insurer (that sells “individual” policies) regardless of your health condition. A.R.S. § 20-1379.

Pre-Existing Conditions: Health insurers may not impose a pre-existing condition waiting period of more than 12 months on any group member and must reduce or eliminate the waiting period in accordance with the employee’s prior “creditable coverage”. A.R.S. § 20-2310.

Balance Billing: Healthcare providers cannot “balance bill” patients for covered, innetwork services to HMO enrollees. A.R.S. § 20-1072.

Emergency Care Access: You have the right to receive EMERGENCY screening and stabilizing treatment services without prior authorization from your health insurer. A.R.S. § 20-2803.

Newborns: When family health or dental coverage is in place, newborns and newly adopted children are automatically covered for 31 days; insurers MUST add the child to the policy if requested and paid for within 31 days. A.R.S. §§ 20-1402(A)(2), 201342(A)(3), 20-1057(B), 20-826(E), 201007(B).

Conversion: Under most health policies, dependents have the right to convert to their own policy following death or divorce of the named insured. A.R.S. §§ 20-1057(M), 201377, 20-1408.

Breast Reconstruction: Insurers must pay for breast reconstructive surgery and at least 2 external postoperative prostheses following a covered mastectomy. A.R.S. §§ 20-1402(A)(5), 20-1342(A)(9), 20-1057(I), 20-826(H).

Non-Formulary Drugs: HMO’s covering prescriptions must have a process for both medically necessary non-formulary drugs, and for drug availability during non-business hours. A.R.S. §§ 20-1057.02(B) 20841.05(B).