Individual Medical Insurance Plans « Health Insurance Advisory

Individual Medical Insurance Plans

Author: Administrator | Jun 04 2011 | indiv-dental-ins, Individual Medical Insurance Plans

Low cost medical insurance coverage is what all Americans want. Roughly 9% of individuals, families and the self-employed today buy medical insurance in the individual medical insurance marketplace, while 59% of Americans obtain their major medical insurance through an employer sponsored health plan.

If you do not have access to employer sponsored medical insurance, then we can help you understand your options so you can secure an affordable medical insurance plan.  We believe an educated consumer makes better decisions. That is why our goal at is to provide better tools and information to empower consumers.

Factors that influence the cost of major medical insurance

In most states, the premium you pay for an individual major medical insurance plan is based on the applicants:

  1. age,
  2. gender,
  3. place of residence,
  4. health status, and
  5. type of medical insurance plan selected.

Currently, individual major medical insurance is medically underwritten (except for children less than 19 years of age).  That means each applicant is required to provide their health history when they apply for a medical insurance plan. The health insurance company will use this information to assess (underwrite) each applicant’s insurability.  Your build (height/weight), tobacco status, past and present medical conditions, including treatment, prescription drug usage and even high risk hobbies (motorcycling, hand gliding, scuba diving, etc.) can affect your insurability and the medical insurance premium you pay.

Note: The new healthcare law, called the Patient Protection and Affordable Care Act, requires health insurance companies to cover children less than 19 years of age regardless of their health status, effective September 2010.  This new mandate is applicable to group or employer sponsored health insurance and individual major medical insurance plans.

Effective January 2014, health insurance companies must accepts all applicants, regardless of their health status, and must cover pre existing medical conditions.

What happens if I do not disclose all of my health status?

Many people wonder about the consequences of not truthfully and completely answering the medical questions on the major medical insurance application.  Withholding information from a medical insurance company can have very serious consequences.  It is very common for health insurance companies to issue a medical insurance policy based on the applicant’s responses to the health questions on the application. If the health insurance company believes there is no reason to ask for medical records or dig deeper into the applicant’s health status to process the application, they will not.

The health insurance company can request medical records, however, after claims are submitted.  This process is called medical review.  The purpose is to validate if the claims were related to a health condition that existed prior to the medical insurance policy going into effect.  Not all claims are subject to medical review. While the new healthcare law limits health insurance companies ability to rescind (retroactively cancel) or reform (modify) coverage (there must be fraud or intentional misrepresentation on behalf of the applicant), an individual could be left with no medical insurance and required to pay their legal expenses and medical bills. Bottom line: always answers health questions on any insurance application honestly and completely. Learn more about recission of major medical insurance.

What if I have pre existing medical conditions?

With the passage of the new healthcare law, new consumer protection rules went into effect in 2010.  They are:

  • Children less than age 19 must be accepted for major medical insurance (“guarantee issue”) and health insurance companies must cover their pre existing conditions. Learn more about guaranteed dependent medical insurance.
  • Young adults less than age 26, can remain on their parent’s major medical insurance plan, regardless of their place of residence, parental financial dependence, and marital, employment or student status. Learn more about securing dependent coverage up to age 26.

While this is positive news, individuals age 26 and older can still be medically underwritten until January 2014.  As a result, the medical insurance company can decline to issue a medical insurance policy or place an Exclusionary Endorsement on any pre existing condition(s). This endorsement effectively excludes the specified health condition(s) from being covered for at least one year.  If you find yourself in this situation, then request the health insurance company remove the endorsement after the first 12 months.

If you have an existing health condition and unsure how it will impact your ability to obtain an individual major medical insurance plan, then use our exclusive Insurability Profile Tool™.  It is fast, confidential and free.  You will receive immediate feedback regarding how a medical insurance company will likely respond to your health status. Learn more about my insurability.

  • Beginning in 2014, the new healthcare law requires health insurance companies to accept all applicants who apply for an individual major medical insurance plan, regardless of their age or health status. Additionally, coverage cannot be restricted in anyway. Pre existing conditions must be covered.

Types of major medical insurance plans

Many different types of major medical plans are offered by health plans and medical insurance companies today, such as:

  • HMO (Health Maintenance Organization)
  • PPO (Preferred Provider Organization)
  • POS (Point of Service)
  • Indemnity

The primary differences between these plans are the:

  1. type of healthcare provider network offered (or not in the case of Indemnity medical insurance plans),
  2. the rules surrounding use of network providers (flexibility to use any healthcare provider or requirement to obtain a referral to see a specialist), and
  3. the plan’s emphasis on preventive care.

In the past, HMO’s were known for their emphasis on preventive care and treating potentially serious health conditions before they manifested into big dollar claims. PPO, POS and Indemnity plans, on the other hand, historically did not cover proactive treatment (routine check ups and screenings). Over the years though, most states enacted wellness benefit mandates.  As a result, these plans evolved to cover routine physicals, mammography, pap smears, cancer screenings, etc.

Since the new healthcare law was passed, all major medical insurance plans are now required to cover the cost of preventive care, as recommended by the U.S. Preventive Services Task Force at 100%. Learn more about the preventive care services mandated by the new healthcare law.

Consumers now have greater piece of mind knowing that all medical insurance plans are required to cover the same preventive care benefits.  This is one reason why high deductible PPO Plans are more attractive today.  Individuals and families can benefit from paying a lower premium and having  preventive care services covered at no charge.  Learn more about high deductible medical insurance.

For even greater financial savings, many individuals open a Health Savings Account with a qualified high deductible plan. The added tax savings from paying for out of pocket qualified healthcare expenses with pre tax money can significantly improve one’s financial situation.  Learn more about the advantages of Health Savings Accounts and how they work.

Learn more about the different types of major medical insurance.

What are my options for medical insurance?

Depending on your situation, several options may be available to you for major medical insurance.  For example, if you were recently covered under an employer sponsored health insurance plan, then you may have certain rights to continue that coverage or purchase an individual major medical insurance plan regardless of your health status. Identifying these alternatives and helping you understand them is our mission at

COBRA continuation coverage

Passed by Congress in 1985, the Consolidated Omnibus Budget Reconciliation Act requires health insurance continuation coverage be offered to employees, their spouses, their former spouses and their dependent children when group health coverage would otherwise be lost due to specific events. Continuation coverage must be made available for 18, 29, or 36 months. Although generally expensive, COBRA can be an excellent alternative for individuals who cannot obtain an individual or self-employed medical insurance policy due to pre existing health conditions. Learn about COBRA eligibility requirements and other important details.

Conversion policy

For individuals currently covered under an employer (group) health insurance plan that are leaving the employer, it might be possible to convert the job-based health insurance plan to an individual medical insurance plan. This is called “conversion” coverage. It is not the same as COBRA continuation coverage because benefits are usually reduced or limited. Contact your employer for information.

HIPAA coverage

The Health Insurance Portability and Accountability Act (HIPAA) guarantees the right to purchase private major medical insurance to “HIPPA eligible individuals,” regardless of their health status. HIPAA also prohibits health insurers from excluding pre existing conditions under the medical insurance plan.

A “HIPAA Eligible Individual” is someone who has/ is:

  1. Had continuous (no break in coverage for 63 days or longer) credible medical insurance coverage for at least 18 months with the most recent coverage being under a group health plan,
  2. Lost group coverage due to circumstances other than fraud or non-payment of premium (whether you quit your job, were fired or laid off does not matter),
  3. Elected and exhausted COBRA continuation coverage, if eligible (employers less than 20 employees are not subject to COBRA),
  4. Not be eligible for coverage under another group health plan, Medicare or Medicaid, and
  5. Not currently covered under a medical insurance plan

Depending on the state, “HIPAA eligible individuals” may purchase individual medical insurance directly from health insurers or their state’s High Risk Pool. These plans are required to offer individual medical insurance regardless of a person’s health status.  Learn more about HIPAA.


Medicaid offers healthcare coverage to certain people with limited income that meet their state’s Medicaid eligibility requirements. Generally, children and parents, pregnant women, people with disabilities and seniors are included. Medicaid programs are run by states with a mix of state and federal funding. There are certain core rules all states must follow, but some Medicaid rules vary by state.

Since most states are currently facing severe budget deficits, Medicaid eligibility rules and benefits may have recently changed. Visit our Government Plans section for links to your state’s health insurance programs.

State Children’s Health Insurance Plan

If you are seeking health insurance for your children, President Obama signed the Children’s Health Insurance Bill on February 4, 2009.  It enables millions of children to receive medical insurance. The eligibility rules for the Children’s Health Insurance Plan are unique because every state has its own program and rules. Generally, uninsured children 18 years old and younger whose families earn up to $44,500 a year (for a family of four) are eligible for free or low-cost medical insurance that pays for doctor visits, dental care, prescription medicines and hospitalization.  Visit our Government Plans section for the  link to your state’s Childrens Health Insurance Plan.

Pre Existing Condition Insurance and High Risk Pool Plans (PCIP)

The PCIP is a new program under the new healthcare law. It is administered by either states or the Federal government. The PCIP may help if you are unable to qualify for individual major medical insurance and meet the following qualifications:

  1. Uninsured for at least six months
  2. Have a pre existing medical condition(s), and
  3. Have been denied coverage (or offered insurance without coverage of the pre existing condition) by a private health insurance company.

The PCIP covers major medical and prescription drug expenses. You are responsible for paying premium, deductible, copayments, and coinsurance amounts. The PCIP will not cost you more just because of your health condition.  Unlike Medicaid, eligibility for the PCIP is not based on income. Visit your state’s specific medical insurance page within for more information regarding the PCIP.

Guaranteed Health Insurance

If you are unable to qualify for major medical insurance, then Guaranteed Health Insurance, also called pre existing condition medical insurance may be an alternative. Since most guaranteed health insurance plans are not medically underwritten acceptance is guaranteed.  While considered supplemental medical insurance, not major medical insurance, these plans typically pay a fixed dollar amount for covered healthcare expenses, such as physician office visits, diagnostic services, lab, x-ray, surgery, inpatient confinement and wellness.

The primary reasons individuals purchase guaranteed health insurance is because they:

  1. Cannot qualify or afford individual major medical insurance
  2. Want an ID card to gain access to the healthcare system in the event that unexpected medical care is needed
  3. Want some financial protection against expensive medical bills

Learn more about pre existing condition medical insurance.

Short Term Medical Insurance

If you are healthy and need major medical insurance for less than 12 months, then short term medical insurance is something to consider.  These affordable temporary health insurance planshelp individuals fill a short-term gap in coverage.  Short-term medical insurance also helps individuals maintain continuous health insurance coverage in order to maintain HIPAA eligibility status. This is important because HIPAA eligible individuals are guaranteed the right to purchase individual major medical insurance, regardless of their health status.  Learn more about short-term medical insurance.

Let us help you find and secure an affordable individual medical insurance plan today!  Our online medical insurance quotes make it fast and easy to shop and compare medical insurance plans from many of the top health insurers in your area. You can even apply online too!

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