INDIVIDUAL MARKET

If other group coverage, COBRA or public assistance is not a possibility, you will need to shop for individual coverage.  Be timely about pursuing your options because you do not want to go over 63 days without coverage or you could lose your exemption from coverage for any pre-existing condition.

A pre-existing condition is a health condition that you or a family member has for which that you have received treatment or for which that any prudent person would have received treatment for in the last twelve months.  One feature of the Health Insurance Portability and Accountability Act (HIPAA) enables a person to have portable health insurance credit so that you can move from one plan to another.  If you are covered under a qualified plan for twelve months another qualified plan cannot limit conditions that you had previously.  Group, private plans, and Medicaid or Peachcare for Kids are all considered qualified plans that supply credible coverage.

This is only applicable if you go from group to group or from private plans to group.  The portability does not help you if you apply for individual coverage.  This is one of the main pitfalls of private insurance besides the premiums.  When you one day return to group coverage, your individual coverage will count as credible coverage.

If you decide to seek private insurance, there are several items that you must keep in mind.

First of all, decide what sort of plans the different carriers offer and what would best fit your needs. You can do this by visiting websites of companies that sell individual policies in Georgia or contact an insurance agent.   The most common types of plans are Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPO), or Indemnity Plans which are usually referred to as Traditional Insurance, and High Deductible Health Plans (HDHP).

HMOs are plans that were designed in an effort to manage your health care.  A person chooses or is assigned a health care home which is an internist or family practitioner.  This provider is in a network of physicians or providers and manages your care and serves as a gatekeeper for your care.  This provider is in charge of referrals if you are in need of a specialist.  You must see a provider in the network because traditionally, there is no coverage if you see a provider outside the network unless it is for an approved emergency.   You are responsible for co-pays for medical, hospital and related visits, and prescriptions.  These co-pays vary widely.

PPOs are still composed of networks of physicians and providers but you usually manage your own care and can go to any provider or specialist in the network.  You are responsible for co-pays for your visits as well as an annual deductible.

While only 8% of Georgians are covered by private individual policies, almost half of the complaints filed with the Georgia’s Office of Insurance and Fire Safety concerning health insurance involve an individual policy. 

Individual plans are quite difficult to qualify for and purchase unless you are healthy. There are very few legal protections for you in the matter of securing a policy.  Read carefully everything you receive from insurance companies giving you the chance to apply for one of their plans.

If you are a student and not on a parent’s health insurance, you might qualify for student insurance at a more reasonable cost through the companies that sell insurance in Georgia.  Also, universities and colleges usually provide students the option of selecting their student health insurance plan.

Understanding the Process

You must list all the doctors and treatments that you have had in the past.  This includes information about each person that applies. 

Make sure you understand what “limited benefits mean”. This means that there is a capped amount that the insurer will pay for a particular expense. For example, a plan might state that $5,000 is the maximum amount to be paid for a hospital stay, meaning you would be responsible for the rest if you had a stay costing $15,000.

On many individual policies, certain categories of health care are not covered at all such as maternity benefits or psychological care. 

Make sure that what you are buying is a real insurance plan and not a discount plan.  Discount plans advertise themselves similar to insurance plans and offer so called discounted medical services.  Often they do have a provider network but you end up paying up to 90% of the cost of services.

"Affordable Coverage" usually means very bare bones coverage with lots of limitations.  The plans that offer benefits similar to group coverage are very costly and average at least $900 - $1200 per month for a family.

You will have to submit the first month’s premium with your application.  It will be returned to you if you are not accepted. 

Keep in mind that if you apply for a family, one or more of you might be accepted and the others declined.

Georgia has very limited oversight for its individual market and very few consumer protections.

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