HIPAA Guaranteed-Issue Health Insurance For California Residents (California) - The David Fluker Health Insurance Agency - Gilroy, California

For those who are exhausting COBRA/CalCOBRA programs or are losing group health coverage with no employer continuation offering, HIPAA regulations allow you to purchase guaranteed-issue health coverage under the following rules:

-COBRA or CalCOBRA benefits must be exhausted or not offered;

-You must apply for HIPAA coverage within 63 days of termination of COBRA, CalCOBRA or employment if no COBRA offered;

-You must have been covered for 18 months continuously prior to HIPAA effective date with the most recent coverage being employer-sponsored group health insurance with no gaps greater than 63 days between any prior coverage;

-Must not be enrolled in nor eligible for Medicare Part A or B, Medicaid or MediCal or covered by another group health insurance plan.

If you qualify and are not medically able to obtain a private underwritten health insurance plan (which would normally be less costly), you can choose a guaranteed issue health plan. Below are plan options and rates for California residents. Please note that you do not need to be declined for individual coverage to elect a HIPAA plan.

HIPAA Individual & Family Plans

ANTHEM BLUE CROSS

Anthem Blue Cross offers the 1500 and 2500 while Anthem Blue Cross Life & Health offer the 5000 and Basic 1000.

Anthem Blue Cross HIPAA Brochure Including Plan Summaries, Rate Guide and Application Form (1/2009)
(Note rates were decreased in the first quarter of 2009 and the above information reflects the reduced rates)

BLUE SHIELD OF CALIFORNIA & BLUE SHIELD LIFE & HEALTH

Blue Shield CA offers the Spectrum PPO 1500 and PPO 2000 plans. Each plan is offered twice, one for each registration (DMHC and DOI) and prices are differentiated between the two plans.

Blue Shield CA HIPAA Rate Guide (2009)
Blue Shield CA HIPAA Application Form
Blue Shield CA HIPAA Plan Summary

HEALTH NET OF CALIFORNIA

July 1, 2009 rate change for Health Net. Health Net CA offers four plans under HIPAA, 2 HMO plans and 2 PPO Plans, one of which is HSA-compatible. Health Net is currently the only carrier offering HSA plans under HIPAA.

HMO Plans are the HMO 15 and HMO 40
PPO Plans are the SimpleChoice HSA and SmartValue 50

Health Net CA HIPAA Brochure with Rate Guide (07/2009)
Health Net CA HIPAA Application Form (07/2009)

AETNA

July 1, 2009 Major Change. Aetna has retired the 1500 PPO plan and replaced it with a $5000 PPO plan. A rate change goes into effect 7/1/09 which is a huge rate increase.

Aetna HIPAA Application Form
Aetna HIPAA MCOA PPO 2500
Aetna HIPAA MCOA PPO 5000
Aetna HIPAA Rate Guide (7/1/2009)

KAISER PERMANENTE OF CALIFORNIA
Kaiser does not allow agents to sell or service their HIPAA plans. You must purchase a HIPAA plan direct from Kaiser.

Important Notes About HIPAA in California:

Be aware that in California, under HIPAA guaranteed-issue coverage, you are only permitted to make one plan election and enrollment. This means that once an insurer has enrolled you in their HIPAA plan, you cannot change carriers or even make plan changes with that carrier after the fact. It is important to be careful when electing coverage under HIPAA as it is a one-time choice as long as you remain under a HIPAA guaranteed-issue health plan.

Many have asked the reason for this rule. According to the health insurers, it is because once you have been enrolled under a HIPAA plan, you are considered to be under individual & family coverage and not group coverage. HIPAA eligibility requires that your last coverage be group coverage. Therefore, by enrolling under a HIPAA plan in California, you lose you further eligibility under HIPAA and cannot enroll in another plan since you are, technically, no longer eligible for HIPAA.

A word about HIPAA start dates
While HIPAA plans are intended to provide guaranteed-issue coverage after COBRA, it is important to bear in mind the effects of start dates in coordinating coverage, especially if your COBRA continuation terminates on an odd date (like the 12th of the month).

HIPAA HMO plans can only start on the first of the month following application. This means that if your COBRA expires on the 20th of the month, you will have a 10-11 day gap in coverage until the HIPAA HMO effective date. HMOs cannot coordinate to last COBRA date except for those whose COBRA ends on the last day of the month. Also, applications for HIPAA HMO plans really need to be received at my office by the 15th of the month prior to the requested HIPAA start date to ensure sufficient processing time.

HIPAA PPO plan start dates vary by health insurer. Currently the rules are as follows:
Anthem Blue Cross - Any start date back to last COBRA date

Blue Shield CA - Any date of month following app submission1st - 31st (effective 8/1/07) of the month (no retroactive coverage for applications received after the requested start date

Health Net CA - 1st or 15th following application approval

Aetna - 1st or 15th following approval of application

Also be aware the even though HIPAA is a guaranteed-issue situation to those who qualfiy, it is not immediate enrollment. Carriers can take several weeks to complete enrollment under HIPAA, so be prepared for that. Also, in order to expedite the process of HIPAA enrollment, you should ensure that you can provide the following with your application:

- Certificate of Creditable Coverage showing expiration of benefits and at least 18 months of coverage; this is also referred to as a Certificate of Group Health Coverage

- COBRA certificate or letter from health insurer or employer (if self-funded/self-insured) showing exhaustion of all continuation benefits (usually provided 30-60 days before the end of COBRA); this is also referred to as a COBRA Termination Letter and can be a letter from the employer, health plan or administrator indicating that your continuation coverage will be or has come to an end due to maximum period allowed.

- If you were not eligible for the CalCOBRA continuation extension to 36 months under AB 1401, proof that the plan did not qualify for that extension (out-of-state, self-funded, etc.). They will ask for written proof in these situations and will NOT take your word for it. You must be able to prove a valid reason for not getting the second 18 months under CalCOBRA in some official manner

-Loss of continuation due to company terminating health plan.You will need to provide some proof in writing that the employer has discontinued health insurance continuation coverage.

	Anthem Blue Cross	Blue Shield CA	Health Net CA	Aetna
Start Date	PPO - Any start date of the month with retroactive start date back to last continuation coverage date	PPO - Any start date of the month 1st - 28th, no retroactive start dates Effective 8/1/07 Blue Shield has any PPO start date 1st - 31st of the month.	HMO - First of the month only PPO - 1st or 15th of the month after application approval, no retroactive start dates	PPO 1st or 15th of the month only after application approval, no retroactive start dates
Application Deadlines /Restrictions	Must apply and be enrolled within 63 days of loss of continuation	Must apply within 63 days of loss of continuation; Must submit application prior to requested start date	Must apply within 63 days of loss of continuation; Must submit application prior to requested start date	Must apply within 63 days of loss of continuation; Must submit application prior to requested start date
Required Documents	HIPAA Application, Certificate of Group Health Coverage with end date, COBRA expiration letter, explanation letter if not on Cal-COBRA extension	HIPAA Application Any other documents available	HIPAA Application Any other documents available	HIPAA Application Any other documents available
Time Frame to Apply	Must apply and be enrolled within the 63-day window	Must apply within the 63-day window but can be enrolled after the 63-day period	Must apply within the 63-day window but can be enrolled after the 63-day period	Must apply within the 63-day window but can be enrolled after the 63-day period