Health Benefits Advisor: Childbirth or Adoption: Other Health Coverage (Consumer Pages)
Health Benefits Advisor: Childbirth – Other Coverage
You may be able to buy health coverage for yourself and your family other than through your job or your spouse’s job, Medicaid, Medicare or SCHIP (State Children's Health Insurance Program). Coverage may be available from an insurance company or an HMO (health maintenance organization) or through your membership in a student, professional or other type of association. In addition, some states also make health coverage available through high-risk pools. Generally, your state insurance department regulates the kinds of coverage offered, the cost of the coverage and the terms and conditions of the coverage.
In addition to any other health coverage that might be available, each state must "guarantee access" to health coverage with certain features for eligible individuals.
Guaranteed Access to Coverage for Eligible Individuals
To be an eligible individual with guaranteed access to health coverage, you must meet the following requirements:
- You had health coverage for at least 18 months without a significant break in coverage;
- Your most recent period of coverage was under a group health plan;
- Your group coverage was not terminated because you committed fraud or did not pay your premiums;
- You either were eligible for COBRA continuation coverage or coverage under a similar state program and you both elected and exhausted the temporary continuation of coverage; or you are not eligible for coverage under your group health plan (for example, because your employer, employee organization (such as a union) or both, does not offer a plan or you have reached the plan’s lifetime limits), under another job based group health plan, under COBRA, or under Medicare or Medicaid; and
- You do not have any other health insurance coverage.
In addition, each family member who wants guaranteed access to coverage as an eligible individual must meet these requirements unless state law provides otherwise.
The coverage that states must make available to eligible individuals (known as “federally eligible” or eligible under the Health Insurance Portability and Accountability Act (HIPAA)) must have the following features:
- The coverage has no pre-existing condition exclusions or limitations;
- The coverage cannot be denied based on the eligible individual’s health status or because he or she is “uninsurable”; and
- The coverage, generally, is renewable at the option of the eligible individual.
Depending on the state, coverage with these features may be offered through an insurance company (including an HMO) or a state high-risk pool. States may also regulate the cost, terms and conditions of this coverage as long as the coverage meets the above requirements. For information about eligible individuals, contact the Centers for Medicare and Medicaid Services or your state insurance department.
How to Choose Among Health Coverage Options
Depending on your circumstances, you and your family members may have health coverage options available besides guaranteed access coverage for eligible individuals. Before making any decisions, you should carefully consider information about other coverages for which you and your family members may qualify.
In choosing among the options available to you, you should review the SPD (summary plan description) for each available group health plan to determine which plan best meets your needs. You should also review and compare the information on the other coverages for which you are eligible. In making your decision, you may want to consider such things as:
- Any waiting period (or affiliation period) imposed under the plans;
- Types of benefits offered (Is dependent coverage available? Do the benefits cover your family's medical needs?);
- Cost of coverage (premiums, co-payments and deductibles for prescription drugs and doctor visits);
- Limitations on coverage (annual or lifetime dollar limits, visit limits, pre-existing condition exclusion periods, prescription drug coverage limits or limits on the availability of doctors and hospitals); and
- Any exclusions from coverage (treatments, procedures, conditions or prescription drugs).
NOTE: Whatever coverage you choose, you should try to avoid incurring a significant break in coverage, especially if you or a family member has a medical condition that requires regular medical attention. A significant break in coverage is a period of 63 consecutive days (or longer in some states) without health coverage. Depending on the circumstances, avoiding a significant break in coverage may enable you and your family to shorten or eliminate any pre-existing condition exclusion period or to qualify for the individual coverage with special protections described above.