Each private insurance company has a list of conditions it considers high risk. Health-Insurance.org, a resource for insurance shoppers, says many companies cite the following:
- Cancers: Usually lung, bone, breast, brain and liver
- Heart conditions: Especially artificial heart valves and coronary artery disease
- Nervous system disorders: Including cerebral palsy, Alzheimer's disease and developmental disabilities
- Immune system disorders: Such as AIDS and scleroderma
Group Health Insurance
There are two basic kinds of health insurance: group and individual. Until the 1996 passage of the federal Health Insurance Portability and Accountability Act (HIPAA), new employees with a high-risk condition could be refused group coverage, or their pre-existing condition could be permanently excluded.
HIPAA ensures that eligible employees are covered by group insurance. It monitors an insurer's requirements in certain areas, including:
- Limited waiting periods: If you've never had group insurance and start a new job that includes it, your high-risk condition cannot have a waiting period of longer than one year.
- Six-month rule: If you've had group insurance, you haven't treated your pre-existing condition during the previous six months and your diagnosis was made more than six months ago, you won't have a waiting period.
- Credit for prior coverage: If it's been no more than 63 days since you were covered within a group, you'll get credit toward the waiting period for the time you were insured.
Many states have laws that are more generous than the federal statutes.
Individual Coverage
HIPAA guarantees individual coverage for those with pre-existing conditions who've had some group insurance for the past year and a half. States carry out this requirement in two ways:
- High-risk pools: These are state- and federally funded insurance groups that cannot turn down any eligible applicant.
- Private insurance: In states with no high-risk pool, private insurance companies must offer at least two policies to eligible buyers.
All applicants must meet these criteria:
- Have near-continuous coverage for 18 months, most recently through a group.
- No longer have group coverage but not as a result of nonpayment or fraud.
- Be ineligible for a temporary extension of group coverage, called COBRA.
- Be unable to get any other coverage, including group, Medicare or Medicaid
Coverage Can Get Costly
High-risk pools can charge much higher rates, sometimes twice the amount of private companies. Many charge only 25 to 50% more than standard rates.
Pool health insurance for people with a $1,000 deductible runs as high as $994 a month, depending on the state, according to the Kaiser Family Foundation.
You can find out if your state is one of those with a high-risk pool by checking with the National Association of State Comprehensive Health Insurance Plans.
If your state has no pool, you must turn to a private company, which is not allowed to impose waiting periods for high-risk conditions. However, there is no limit to the amount insurers may charge.
If you don't meet HIPAA requirements, you may still be able to get individual insurance under your state's high-risk pool, according to Robert Zirkelbach of America's Health Insurance Plans, a legislative lobbying group for the health insurance industry in Washington D.C. Or you may be able to get insurance from a private company.
Insurance companies are not capped on the amount they can charge if you're ineligible under HIPAA. You will may pay up to three or more times the amount for someone with no high-risk condition.
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