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Health Care & Insurance

Health Coverage for All

How to find an affordable policy even if you're not healthy.

Worries about losing health coverage can make you reluctant to leave a job, start a business, move to another city, get divorced or retire early. And that's especially true if you have a medical condition.

But you don't have to let health insurance rule your life. Although it won't necessarily be easy, chances are you can find good coverage on your own -- often for less than you might expect -- even if you're not in the best of health. All four of the following strategies have been used successfully by the families profiled below.

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Shop the market

Each insurance company has its own rules about who it will cover. Depending on your medical condition, one insurer may reject you, another may add a 50% surcharge to your premium, and a third may cover you at standard rates. "Some companies reject as few as 5% of their applicants, and others may reject 15% or 20%," says Russ Childers, a health-insurance broker in Americus, Ga. For high-risk clients, Childers has the best luck finding coverage through Blue Cross and Blue Shield of Georgia, which serves more than 60% of the market in his area and can spread its risk over more patients.

Although most insurers reject individuals with diabetes, for instance, a few have begun offering coverage to people who control the ailment through diet or oral medicine, rather than insulin injections. Some insurers reject anyone who has been diagnosed with cancer, while others offer coverage five or seven years after a patient's last treatment. Each insurer has specific cutoffs for height, weight, cholesterol and blood pressure, and a few reject applicants with minor problems, such as seasonal allergies. What's more, states have different laws regarding coverage.

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As a result, the range of policies and premiums is wide, as Mike Golm and his wife, Mary Lukanitsch, discovered. The Lake Forest, Ill., couple paid about $780 per month for COBRA coverage through Golm's former employer after he retired three years ago at age 57. Golm's COBRA would have expired after 18 months, and when the couple began shopping on the Web for new policies, they found a price range of $597 to $860 for similar coverage.

But the couple suffer from medical conditions "fairly typical for people in our age group," says Golm -- high blood pressure, elevated cholesterol and osteopenia (low bone density) -- and they were turned down by AARP, Blue Cross and Unicare. They could have qualified for coverage through the Illinois Comprehensive Health Insurance Plan (the state's high-risk pool), but those premiums were $1,500 per month, and the plan usually has a waiting list. So they continued to shop.

Humana finally offered them a policy for $1,100 per month, with a $1,000 deductible and some exclusions -- more than they were paying under COBRA but less than the high-risk pool would cost. This year they avoided a 15% premium hike by increasing their deductibles to $1,750, and they're counting the years until they turn 65 and qualify for Medicare.

Golm and Lukanitsch shopped on their own, but you can save time -- and possibly money -- by working with a health-insurance broker who is familiar with your local market. Find a broker through the National Association of Health Underwriters or work with eHealthInsurance.com (if you have medical problems, it's easier to call 800-977-8860 for personal service rather than going online). Mention your medical conditions immediately, so you don't waste time with insurers who will likely reject you once they see your records. A rejection by one company could make it tougher to get coverage elsewhere.

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Fight back

Sarah Leath had health insurance through an association for dental employees. But after premiums increased several times, the 40-year-old Indianapolis woman was paying $300 per month for coverage that had a $2,600 deductible. "I didn't feel it was worth paying that much for insurance I rarely used," says Leath. She began looking around for individual coverage, only to discover that insurers didn't consider her as healthy as she thought she was.

For instance, Central Reserve Life wanted to exclude coverage for ten years for any disease or disorder of the cervical back or spine because Leath had been in an auto accident in 2002 -- even though she's been "fine ever since." The company also wanted to exclude coverage for anything related to endometriosis, a condition that Leath has but that doesn't require treatment.

Leath's agent, Nicole Fairbairn, talked with Central Reserve Life, provided test results, clarified information from Leath's application and got the endometriosis exclusion reversed. Leath's premium increased by 20% over the original quote, but she's still paying only $187 per month -- far less than with her former group coverage. Her upper-back problems are still excluded, but in a few years Fairbairn plans to provide new medical records plus a doctor's statement to try to get that exclusion reversed as well. "Don't take no for an answer," advises Leath. "Find out why, and look for an agent who's willing to help you."

Insurers are required to provide a letter spelling out why you've been rejected, says Robert Hurley, vice-president of eHealthInsurance, so be sure to ask for one. A doctor's intervention could convince an insurer to reverse its decision. For example, insurers sometimes reject applicants who take anxiety medications when they fly because it shows up on their medical records as a mental-health drug, says Hurley. But an insurer might reconsider if a doctor explains that the drug was prescribed specifically for flying.

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Similarly, if you're undergoing counseling, it's helpful if a doctor explains that the treatment is related to a particular situation, such as a death in the family, rather than chronic depression. And it doesn't hurt for a physician to tell an insurer how well you've been managing your condition over the past few years. Even something as simple as getting a doctor's note to clear up an error in your medical records, such as a wrong date, can make a difference in whether you're accepted or rejected by a company.

Know the rules

In most states, insurers can reject you for individual coverage because of a medical condition (see the box on the facing page for a look at states where you can't be rejected). But even if you don't qualify for individual health insurance, you may still be able to get coverage.

For example, employers with 20 or more employees are required to let you continue group coverage under the federal COBRA law for up to 18 months after you leave your job (some states have similar laws covering smaller workforces). You'll have to foot the entire bill, without the 50% to 75% subsidy generally provided by employers. But the insurer can't reject you or raise your rate because of your health.

Even if you don't have medical problems, it pays to sign up for COBRA when you leave a job and to maintain it until you qualify for another individual or group policy elsewhere. But COBRA is a temporary solution, so you need to find alternatives.

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In 33 states, high-risk pools can provide coverage if commercial insurers reject you. Most cap their premiums at 125% to 150% of the cost of standard coverage, and they may have lower benefit caps than commercial policies. But some state pools have long waiting lists or, like Florida's, are closed to new applicants. Arizona, Georgia and Nevada are among the states that have no high-risk pool. For information about your state's pool, contact the National Association of State Comprehensive Health Insurance Plans or Communicating for Agriculture's Risk Pool Resource.

If you're shut out of a high-risk pool, your ace in the hole may be the Health Insurance Portability and Accountability Act of 1996 (HIPAA). That law requires insurers to provide you with some type of coverage after you leave your job -- regardless of your health condition -- as long as you had an eligible group policy and haven't been without coverage for more than 63 days in the preceding 18 months.

You generally have to exhaust your COBRA coverage first. After that, each state has its own HIPAA rules, so contact your state insurance department before dropping your old coverage. Insurers who are regulated in Florida, for example, tend to charge 200% to 300% of their standard rate for their HIPAA policies, says John Sinibaldi, a health-insurance broker in Seminole, Fla. (Another source of information is NAHU's Consumer Information Center.

A HIPAA continuation policy was a godsend for Cheryl Crawford, 50, of Chino Hills, Cal. Crawford had coverage through a group HMO with Kaiser Permanente when she owned a small insurance brokerage. But she no longer qualified for a group policy after she sold her business. In the meantime, she had developed a rare blood disease. Kaiser rejected her for individual insurance but offered coverage under a HIPAA continuation policy. "It was just a matter of how much I'd have to pay," says Crawford.

Her premiums nearly doubled, to $484 per month. But she was permitted to keep her doctors, and her co-payments remained a reasonable $25 per office visit and $10 per prescription, so the new policy limits her out-of-pocket costs. Even when she began an oral form of chemotherapy to help break up blood clots, she still paid only $10 for a two-month supply. "That makes a huge difference to me," says Crawford.

Beware of gift horses

Although it's possible to find deals on health insurance even if you're not in good health, coverage is rarely cheap. "If you end up with a plan that's 20% to 30% below the market price, that's a big red flag," says Fairbairn. An insurance company may lowball the price to get you to sign up, and then proceed to hike premiums for the next several years until you're paying a lot more than you would for other options.

Mark and Noreen Eccleston have bought their own health insurance for the past 20 years, ever since Mark, 62, left his job as a mechanical engineer and started his own company repairing freezer units used by food distributors. The Ecclestons, of Greenwood, Ark., would find low-cost policies through various group associations for self-employed people, watch the premiums climb year after year, and then shop around for another association policy.

That's a common experience among people who buy policies through small groups that members join primarily to get health insurance. Policies offered by large professional organizations can work well because the group is able to negotiate with insurers for good rates. But small organizations don't have that kind of leverage. They tend to attract people with health problems who can't qualify for individual coverage. So when patients begin submitting claims, insurers are usually forced to raise the price for everyone. Members who are healthy desert the plan to find cheaper coverage elsewhere, leaving the group with a less-healthy pool of policyholders -- what insurers call an "actuarial death spiral."

Things finally came to a head for the Ecclestons after Noreen, 60, incurred $50,000 in medical bills as the result of an auto accident in 1992. Her bills were covered, but the insurer gradually started to boost the couple's premiums, until they went from $250 per month to $1,000.

Sick of the spiraling costs, the Ecclestons went to eHealthInsurance.com to shop for individual policies, which are subject to different rules than group plans. Noreen hadn't been treated for accident-related injuries for nearly a decade, and the Ecclestons qualified for an individual policy with Golden Rule for $400 per month.

They chose a policy with a $2,500 deductible and are making tax-deductible contributions to a health savings account to pay for out-of-pocket expenses. "All we need is disaster insurance in case something really bad happens to us," says Noreen. They've had few medical expenses since they bought the policy, so they're amassing a pot of cash they can use over the next few years, or even after they qualify for Medicare.

It's better to choose a high-deductible policy rather than a bare-bones plan with a lower deductible and a lower annual cap on coverage. A policy with a lifetime coverage cap of $5 million or more is usually safest, says Barbara Bachelder, a financial planner in San Rafael, Cal. Some policies cap their annual payouts at $200,000, which could have fallen significantly short of paying the bill for Bachelder's kidney transplant seven years ago.

Bachelder is fortunate to have a group policy through her husband's employer. Regardless of where you get coverage, she recommends that you include out-of-pocket expenses in addition to premiums when figuring the cost of insurance, especially if you have any medical conditions. Bachelder's insurance plan is comprehensive and expensive, but she takes drugs that cost thousands of dollars each month. "For me," she says, "it makes sense to pay more in premiums in return for better benefits."

The Massachusetts experiment

All of the strategies outlined here are useful in states where insurers can raise your rates or deny you coverage based on your medical condition. A handful of states -- notably Massachusetts, New Jersey and New York -- guarantee that you can buy coverage regardless of your health and you can't be charged more because of it.

That sounds good, but so-called guaranteed-issue coverage can cause another big problem -- namely, very expensive insurance for all state residents. That's often compounded by state mandates that insurers cover a long list of medical procedures -- including, in Massachusetts, in vitro fertilization.

Consider this: Cheryl Crawford, who suffers from a rare blood disease and would be rejected by most insurance companies, found a policy in California that costs $484 per month. In Massachusetts, where insurers must charge everyone the same price regardless of their medical condition, even the healthiest person would pay nearly that much.

Massachusetts has been in the spotlight since it passed a new health-insurance law designed to reduce the number of uninsured individuals by requiring state residents to have coverage. Low-income households will receive government subsidies, but middle-income residents still face some of the highest rates in the country for individual health insurance.

For example, according to a recent study by eHealthInsurance.com, a family of four in Boston pays at least $865 per month -- or more than $10,000 annually -- for a policy with a $2,000 deductible and 20% co-insurance (meaning the insurer picks up 80% of a claim after the deductible is met). A family would pay $247 monthly for a similar policy in San Francisco and just $194 in Des Moines. Individuals in Massachusetts now pay $350 to $500 a month for single coverage, says Julie Jennings, a health-insurance broker in Dartmouth, Mass., and president of the Massachusetts Association of Health Underwriters.

Because of high premiums, healthy individuals often decide to forgo insurance because they know they can get coverage if they become ill. "We've created a young population that sees no value in insurance," says Jennings. That means insurers have been losing some of the best people in their risk pool, so there are fewer healthy individuals to help subsidize the cost for those who are sick.

To get more healthy people into the pool, the Massachusetts law, among other things, penalizes residents who don't buy coverage and lets dependent children stay on their parents' plan up to age 25. But it doesn't eliminate the guaranteed-issue requirement, so it's not clear whether prices will come down enough to make the plan a success. "We have a long way to go," says Jennings. For more on the Massachusetts plan, read the analysis at Kiplinger.com.)