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The State of the Individual MarketThe Problems Facing the Individual Health Insurance Market in Massachusetts Insurers limit care by offering those in the individual market weak benefits, and sometimes excluding benefits all together. Insurers will sometimes even cancel an insurance policy once a customer starts making costly claims. Study after study has documented that people with pre-existing conditions can find it nearly impossible to get the coverage they need, or face high costs in trying to purchase it.1 One way insurance companies limit care is by offering coverage on the individual market that has a weaker benefit package than most employers provide.2 Despite these smaller benefit packages, individual insurance policies also usually come with high cost sharing, such as deductibles that average $2,000 for PPO coverage.3 Limiting benefits: Massachusetts requires insurance companies to include 43 benefits in
all individual insurance plans, which is higher than the national average of 38.4 This does
not include basic benefits such as chemotherapy, cancer medications and screenings, and
diabetic self management.
Weakening affordability: Insurers also charge higher rates to those who might need more
care, such as older Americans or individuals with health conditions. Massachusetts has
imposed adjusted community rating. This means that insurers cannot charge people more
on the basis of their health status, but they can adjust rates for other characteristics such as
an applicant’s gender or age.5
Insurers also exclude coverage for medical conditions that individuals know they need. Insurers do this by defining pre-existing conditions as broadly as they can and then exclud-ing those pre-existing conditions from coverage.
Center for American Progress | The State of the Individual Market Broadly defining pre-existing conditions: The more broadly insurance companies can
define pre-existing conditions, the more conditions they can exclude from coverage, and
the less care they will have to pay for. In Massachusetts, you must have received medical
attention for your condition—advice, a diagnosis, or actual treatment—for it to count as
pre-existing.6 This is a higher standard than other states, which allow undiagnosed symp-
toms to count.
Counting recent and old pre-existing conditions: The more medical conditions that
insurers can count as pre-existing—even if they no longer exist—the more they deny care.
In Massachusetts, insurers can look 6 months back into your medical history to determine
if you have a pre-existing condition.7 More than half of states and the District of Columbia
allow insurers to look back more than a year.
Limiting care for pre-existing conditions: Once insurers have identified an individual’s
pre-existing condition, they will limit coverage by sel ing people policies that specifically
exclude coverage for those conditions. In Massachusetts, insurers are allowed to exclude a
medical condition or body part from health coverage for up to 6 months.8 This means that,
although individuals start paying premiums and have coverage for the rest of their body
and any new medical conditions, they will have to wait before they have coverage for the
medical condition they already need care for.
It is possible for insurance companies in the vast majority of states to cancel coverage once insurers discover that expensive claims are being made on the policy.9 In a game of “gotcha,” insurers can compare the original application to a policyholder’s medical history to find any discrepancy—no matter how small, innocent, or irrelevant—in an effort to cancel coverage. This can happen even years after the policy was purchased and in the face of complex insurance applications. Individuals who have their coverage canceled or rescinded are often left with large medical bil s and no insurance moving forward just when they need it the most.
Denying coverage for those who need it now or later: In Massachusetts, insurers are
required to issue coverage to every applicant, regardless of their health status. This means
they cannot cancel or rescind coverage later on the basis of a pre-existing condition. Most
states allow coverage to be denied on the basis of health status at the time of application,
or if a pre-existing condition is discovered later.
Insurance companies will use a range of reasons to limit health insurance on the individual market based on who wants to buy it.
Center for American Progress | The State of the Individual Market Prescription drug use: Taking prescription medications makes mil ions of Americans
ineligible for coverage on the individual market.10 For example, insurance companies
in California bar individuals from coverage if they take any of the eight of the 20 most
popular prescription medications in the United States.11 That includes the top sel ing drug
in the country, Lipitor, which has been prescribed to more than 26 mil ion Americans to
treat cholesterol.12
Height and weight: Health insurance will cost more for the approximately one-third of
adults who are medically obese13 (a BMI of 30 or higher), if it is available at all. Those
with a BMI of more than 35 will simply be denied.14 But it isn’t just the obese who can be
turned down. Coverage can more expensive, or denied, for those deemed too short, too
tall, or too thin.15
Age: Age discrimination is prevalent in the individual insurance market.16 A person who
is 60 to 64 and healthy is going to pay on average four times as much for health insurance
than an 18 to 24 year old—$1,170 per year vs. $4,185 per year.17 Of course, that is only for
those who are offered coverage.18 Those 60 to 64 are three times more likely to be turned
down for individual coverage than those 18-24.19
Gender: Being a woman means paying more for health insurance.20 Pregnancy has long
been a reason insurance companies use to charge women higher rates for health insurance,21
despite the fact many individual insurance policies don’t even cover maternity benefits.22
Occupation: Insurers will use your occupation to decide if you can buy insurance.
Roofing, window cleaning, lumber work, and asphalt laying are occupations that insurers
will sometimes not cover.23 Even hobbies such as scuba diving and skydiving can mean
being denied coverage.24 Volunteer firefighters, a common activity in rural areas, can be
denied coverage even if their full-time occupation only involves office work.25
1 Sara Collins and others, “Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Fami-lies” (New York: The Commonwealth Fundsee: Nancy Turnbull and Nancy Kane, “Insuring the Healthy or Insuring the Sick? The Dilemma of Regulating the Individual Health Insurance Mar-ket, A Survey of Seven States” (New York: The Commonwealth Fundamilies USA, “Failing Grades: State Consumer Protections in the Individual Health Insurance Market,” (2008) ;Karen Pollitz, Richard Sorian, and Kathy Thomas, “How Accessible is Individual Health Insurance for Consumers in Less-Than-Perfect Health?” (Washington: Kaiser Family Foundation, 2001) 2 Nancy Turnbull and Nancy Kane, “Insuring the Healthy or Insuring the Sick? The Dilemma of Regulating the Individual Health Insurance Market, A Survey of Seven States” (New York: The Commonwealth Fundamilies USA, “Failing Grades: State Consumer Protections in the Individual Health Insurance Market 3 AHIP Center for Policy and Research, “Individual Health Insurance: A Comprehensive Survey of Affordability, Access, and Benefits” 4 Victoria Craig Bunce and JP Wieske, “Health Insurance Mandates in the State, 2008,” (Virginia: Council for Affordable Health Insurance, 2008) . Also see Kaiser State Health Facts, “Mandated Benefits in Private Health Insurance,” Kaiser Family Foundation. 5 Kaiser State Health Facts, “Individual Market Rate Restrictions,” Kaiser Family Foundation. Available a. Center for American Progress | The State of the Individual Market 6 Kaiser State Health Facts, “Individual Market Portability Rules,” Kaiser Family Founda 7 Kaiser State Health Facts, “Individual Market Portability Rules,” Kaiser Family Founda 8 Families USA, “Failing Grades: State Consumer Protections in the Individual Health Insurance Market” (2008) 9 Peter Harbage and Hilary Haycock, “Primer on Post-Claims Underwriting” (New Jersey: The Robert Wood Johnson Founda 10 Chad Terhune, “They Know What’s in Your Medicine Cabinet,” BusinessWeek, July 23, 2008. http://www.businessweek.com/magazine/con-tent/08_31/b4094000643943_page_2.htm 11 Lisa Girion, “Health insurers deny policies in some jobs: Common medications also can be deemed too risky in California,” Los Angeles Times, January 8, 2007.
13 Centers for Disease Control and Prevention, “Overweight and Obesity” available a 14 Texas Office of Public Insurance Counsel, “2007 Individual Health Underwriting Guidelines,” State of Texas, 2007. Available at http://www.opic.
state.tx.us/docs/442_2007_health_ug.pdf.
15 Families USA, “Failing Grades: State Consumer Protections in the Individual Health Insurance Market” (2008) 16 Sara Collins, et al, “Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health Sara Collins and others, “Squeezed: Why Rising Ex-posure to Health Care Costs Threatens the Health and Financial Well-Being of American Families” (New York: The Commonwealth Fund, 2006) Also see: “Financial Well-Being of American Families” (New York: The Commonwealth Fund. Also see: AHIP Center for Policy and Research, “Individual Health Insurance: A Comprehensive Survey of Affordability, Access, and Benefits,” (2005) y Turnbull and Nancy Kane, “Insuring the Healthy or Insuring the Sick? The Dilemma of Regulating the Individual Health Insurance Market, A Survey of Seven States,” (New York: The Commonwealth Fund, Februar 17 AHIP Center for Policy and Research, “Individual Health Insurance: A Comprehensive Survey of Affordability, Access, and Benefits,” 18 AHIP Center for Policy and Research, “Individual Health Insurance: A Comprehensive Survey of Affordability, Access, and Benefits,” 19 AHIP Center for Policy and Research, “Individual Health Insurance: A Comprehensive Survey of Affordability, Access, and Benefits,” 20 David Lazarus, “Gender can cost you in individual health insurance,” Los Angeles Times, June 22, 2008. http://www.latimes.com/business/la-fi-lazarus22-2008jun22,0,24096.column 21 Elizabeth Edwards, “Elizabeth Edwards on the Inequitable Individual Market,” (Washington: Center for American Progress Action Fund Wonk 22 Nancy Turnbull and Nancy Kane, “Insuring the Healthy or Insuring the Sick? The Dilemma of Regulating the Individual Health Insurance Market, A Survey of Seven States,” The Commonwealth Fund, February 2005. 23 Lisa Girion, “Health insurers deny policies in some jobs: Common medications also can be deemed too risky in California,” Los Angeles Times, January 8, 2007.
24 Texas Office of Public Insurance Counsel, “2007 Individual Health Underwriting Guidelines,” State of Texas, 2007. Available at http://www.opic.
state.tx.us/docs/442_2007_health_ug.pdf.
25 Lisa Girion, “Health insurers deny policies in some jobs: Common medications also can be deemed too risky in California,” Los Angeles Times, January 8, 2007.
Center for American Progress | The State of the Individual Market

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