TABLE DEFINITIONS:
The following definitions and abbreviations apply to the table below:

Guaranteed Issue:

Requires insurance carriers to offer coverage regardless of claims history or health status.

Preexisting Conditions:

Limits the amount of time a carrier can exclude coverage for a condition that was present before the new coverage began.  Also usually limits the amount of time a carrier can “look back” to consider a condition as preexisting.  The tables list two numbers indicating first, the maximum exclusion time in months, and second, the look-back time in months (i.e., 12/6).  Look-back provisions often use one of two specific standards and definitions:

1. “prudent person” definition, meaning that the average layperson would have sought treatment or advice for the given condition.  This means that actually consulting a health care provider is not always necessary for a condition to be considered preexisting.
2. “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 under 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 is at fault (e.g., failure to pay premiums, fraud).  Note 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 conditions.  If a state notifies CMS that it has not enacted legislation to enforce or that it is not enforcing HIPAA requirments, then CMS becomes responsible for that function.

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 is at fault (e.g., failure to pay premiums, fraud).  Note 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 conditions.  If a state notifies CMS that it has not enacted legislation to enforce or that it is not enforcing HIPAA requirements, then CMS becomes responsible for that function.

The table below includes laws on the specific topics current to 2012.

Source: Kaiser Family Foundation, State Health Facts, “Individual Market Portability Rules (Not Applicable to HIPAA Eligible Individuals), 2008”

Footnotes for Guaranteed Issue

Only certain states are highlighted here.  For more information click on our navigation on the left which will take you to your states health insurance page. Guarantee issue policies might include one man group plans, risk pools for the uninsurable, and other guarantee acceptance plans.

States like New York or Massachusetts will not have this because the entire state is considered guarantee issue due to the fact that insurance companies are not allowed to decline someone based on medical conditions.

Note: Details and updated data provided by “Health Policy Institute, Georgetown University” as published by Kaiser State Health Facts- December 2007.

1. California Health Insurance Rules: Insurers for the individual markets and HMOs must guarantee issue a standardized policy to those exhausting High Risk Pool coverage (36 months).

2. Idaho Health Insurance Laws: Individual market insurers must guarantee issue standardized policies to the medically uninsurable. Insurers must offer basic, standard and catastrophic policies. These policies are called High Risk Pool Policies.

3. Iowa Health Insurance Laws: Iowa provides a high risk pool for those who cannot afford coverage in the private markets. The Iowa Individual Health Benefit Reinsurance Association (IHBRA) has been merged into HIPIOWA effective January, 2005.

4. Kentucky Health Insurance Laws: Beginning in 1998 with HB 315, the standardized plans and guaranteed issue requirements were replaced by a complex “pay or play” system that was named the Guaranteed Acceptance Program. In 2000, HB 517 created a high risk pool called the Kentucky Access. These measures were specifically taken to encourage more people to return to the individual markets.

5. Michigan Health Insurance Laws: HMOs, after 24 months in existence, are required to guarantee issue to a limited number of applicants during one, 30 day open enrollment per year.

6. New Hampshire Health Insurance Laws: There were many flaws with the 1994 law on guarantee issue. The greatest conflict being that the law did not require 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 pool was created.

7. Ohio Health Insurance Laws: Individual market insurers must guarantee issue standardized policies on a periodic basis. Non-HMOs are required to guarantee issue standardized policies (up to a limited number determined of enrollees as determined by the state) for one 30 day period, annually. HMOs are required to guarantee issue standardized policies annually until reaching a state determined limited number. For HMOs, this period could extend beyond 30 days.

8. Oregon Health Insurance Laws: Individual market insurers must guaranteed issue portability policies to individuals with 6 months of prior coverage.

9. Rhode Island Health Insurance Laws: Individual market insurers must guarantee issue all products to those with 12 months of continuous creditable coverage, provided the applicant is not eligible for alternative group coverage, Medicare or any other state health insurance plan.

10. South Dakota Health Insurance Laws: The South Dakota Risk Pool was created in 2003 to provide coverage to people who have lost coverage and have previous creditable coverage. However, unlike most high-risk pools, the program does not serve uninsured individuals who have a pre-existing condition or illness that causes them to be declined by private insurers unless the person recently lost creditable coverage.

11. Utah Health Insurance Laws: Individual market insurers that have not met enrollment cap must guarantee issue at least 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 Health Insurance Laws: The insurers must guarantee issue all products to their applicants,  who receives a minimum score on the state mandated health status questionnaire. The applicants that not eligible for guarantee issue are referred to the high risk pool.

13. West Virginia Health Insurance Laws: HMOs with greater than 5 years in the market or with enrollment not less than 50,000, must guarantee issue during annual 30 day open enrollment period.

Footnotes for Pre-existing conditions:

* Cannot be applied to guaranteed issue products.

**Commercial insurers: 6/12, BCBSMI and HMOs: 6/6

1. Connecticut:

-HR 2833: the legislation would allow 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-group, individual plans.

-Charter Oak Plan: The plan would require managed care companies to provide health coverage to residents who have been uninsured for at least six months and are ineligible for publicly funded health plan and charge only the premium.

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

BRIEF LEGISLATIVE HISTORY OF INDIVIDUAL  INSURANCE REFORM

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

2007-08 STATE ACTIONS: Prompted by numerous consumer complaints and lawsuits against insurers, state lawmakers are taking action. Among their efforts:

New Mexico: The Legislature has passed bills requiring insurers to show that applicants deliberately gave incorrect information on an application. Current law allows cancellation if the error or omission was inadvertent. The governor has not said whether he will sign the bills, says spokeswoman Caitlin Kelleher. Without the law, “the consumer has no ability to defend” against a cancellation, says Melinda Silver, attorney with the state’s Managed Health Care Bureau. (SB 226 Signed into law as Chapter 87, 3/4/08)

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

California: California state regulators have announced cancellation-related fines against some insurers, including Blue Cross, Kaiser Permanente and Blue Shield of California.  Legislation introduced in February 2008  would require insurers who want to cancel a policy to first win approval from the state’s Department of Managed Health Care. Last year, legislators adopted a law requiring insurers to pay for any medical treatment they approve, even if they later cancel the policy.

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

Sources: Table updated August 2006 and June  2008 by the NCSL Health Program; selected text adopted from a longer issue brief on HIPAA, originally published 10/3/00 by Health Policy Tracking Service and updated in 2003.  Data also has been compared to online material by Kaiser Family Foundation, at http://www.statehealthfacts.org/comparetable.jsp?ind=353&cat=7 or  http://www.statehealthfacts.org/.

STATE ACTION PERTAINING TO GUARANTEED ISSUE

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 also known as guaranteed issue.  Since many insurance companies consider caesarean section and even pregnancies as preexisting conditions, the insurance companies in these five states would cover the expenses, without future repercussions to the mother. The policies in the following states are Modified Community Rated, which guarantees insurance applicants will not be denied coverage or affect insurance rates due to pre-existing conditions, as long as the applicant has previously maintained continuous coverage.