Under the Affordable Care Act (ACA), plans may not impose any pre-existing condition exclusions as of Jan. 1, 2014 for all ages. Depending on your income, you might be eligible for Medicaid, a state-federal program, which has been expanded as of January 2014. Low-income adults, including those without children, are eligible, as long as their incomes don't exceed 138 percent of the federal poverty level.
Additionally, the Comprehensive Health Association of North Dakota (CHAND), which is administered by Blue Cross Blue Shield of North Dakota, provides health insurance coverage for individuals who, because of their medical conditions or history, have been unable to obtain health insurance from other insurers in this state. A person enrolled in CHAND must pay premiums. By law, the premiums may not exceed 135 percent of the average premium rates charged by the five largest insurers with a similar plan of insurance in force in this state. For eligibility in CHAND, a person must be a North Dakota resident for at least six months and provide written evidence of being rejected for accident and health insurance (or that restrictive riders or pre-existing conditions limitations which substantially reduce coverage were required) by at least one insurance company within six months of the date of application to CHAND. An application for coverage through CHAND may be obtained through any insurance agent licensed in North Dakota to sell accident and health insurance. There is a waiting period after application before coverage is in force for maternity benefits and pre-existing conditions.
Terminated employees or those who lose coverage because of reduced work hours are able to buy group coverage for themselves and their families for limited periods of time under both a federal and state law.
If your employer has more than 20 employees, you will generally fall under the federal law, the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA establishes specific criteria for plans, beneficiaries, and events which initiate the coverage. Coverage is only temporary, ranging from 18 to 36 months. The former employee is responsible for the entire premium (the total of what you and your employer contributed). COBRA outlines procedures for employees and family members to elect coverage continuation and for employers and plans to notify beneficiaries.
If your employer has less than 20 employees, you will fall under North Dakota state law. This law identifies the specific rules and regulations to continue your group health coverage. Like COBRA, coverage is only temporary. You must also pay the entire premium to your employer.
Another option is to purchase insurance through the federally-facilitated Marketplace. Changing jobs is an event that qualifies you to enroll in a new plan, even if this occurs outside the general open enrollment period.
The Affordable Care Act (ACA) requires all health insurance plans sold after 2014 to include a basic package of benefits, including maternity care. If your current insurance policy does not include maternity benefits, you may want to consider purchasing a plan that is required to comply with the essential health benefits.
A new plan may not be as comprehensive as your existing plan, so be sure to carefully review benefits and costs before switching.
Even though you have not had any claims, the theory of insurance involves the pooling of a large number of similar risks, thereby transferring the uncertainty related to the risk from the individual to the insurance company in return for a premium. In this way, the insured person pays a small, immediate known loss (the premium) in return for relief of worry from a possible, large, further loss such as a health claim.
Companies requesting rate increases or decreases for health insurance are required to submit supporting documentation to the North Dakota Insurance Department proving that the rate increase requested is not excessive, inadequate, or unfairly discriminatory. The Department then must analyze the filings to determine if the rate requested is justified.
Companies writing health insurance in North Dakota can revise rates based on the company's "experience" in North Dakota. Experience is the data collected by an insurance company that takes into account premiums collected and claims paid. For every premium dollar received by a health insurance carrier, approximately 80 cents is used to pay for claims and claims processing. The balance of 20 cents goes to pay agents' commissions, general operating expenses, and taxes. If the company is a for-profit organization, state law allows the private company to earn a reasonable profit.
A self-insured group is one in which an employer serves as their own insurer, paying claims from corporate assets. Many of these employers hire a third-party administrator to manage the payment of claims for their employees.
Self-insured groups are not regulated by the state but by the federal government under the Employee Retirement Income Security Act of 1974 (ERISA). Self-insured plans are also exempt from state taxes on insurance premiums.
If you decide you do not want the policy, you have 30 days after the policy has been delivered to return it to the company and receive a full refund. This is a good time to read the policy over and over again during the "free-look" period. Here's what to do:
- Keep the envelope the policy was mailed in or insist your agent give you a signed delivery receipt.
- Return the policy to the company with a brief letter asking for a refund.
- Send the policy and letter by certified mail.
- Your money should be refunded within a couple of weeks.
An individual may sign up for Medicare beginning three months prior to the month of his/her birthday, during the month of his/her birthday, and no later than three months after. This gives a beneficiary an initial enrollment period of seven months.
If you did not sign up for Medicare Part B during the initial enrollment period, you may sign up during the general enrollment period - Jan. 1 through March 31 of each year. If you enroll at this time, your Part B coverage will not start until the following July 1. A person could lose up to 18 months of coverage for failing to sign up on time.
You could also be charged a 10 percent surcharge on the Part B premium for each 12-month period during which you are eligible but not yet enrolled. This surcharge increases each year as the Medicare premiums increase.
If a person declines Medicare Part B at age 65 because of health insurance coverage through their work or spouse's employment, they may enroll in Part B later without a surcharge added to the premium. The special enrollment period lasts seven months and begins when a person or his/her spouse retires.
If you are turning 65, your first priority is to make sure you are enrolled in Medicare Part A and Part B. Contact the nearest Social Security office for information on enrollment procedures. Once you are enrolled in Medicare Part A and Part B, consider whether you may want to purchase additional insurance to supplement your Medicare coverage.
Federal law gives you a six-month open enrollment period to apply for a Medigap insurance policy. The six-month period begins with the first month that you enroll for benefits under Medicare Part B. If you are 65 or older and apply within this six-month period, you cannot be denied Medigap insurance because of health problems. During this period, you have a choice of any of the different Medigap policies sold by any insurer selling Medigap policies in North Dakota. The company cannot deny or condition the insurance, or discriminate in the pricing of a policy because of your medical history, health status, or claims experience. Although some policies do not cover health problems existing at the time of the purchase of the policy, all Medigap policies are required to cover pre-existing conditions after the policy has been in effect for six months.
Look for the words "Medicare Supplement" on the policy. These words identify a Medigap policy that meets minimum federal and state standards. There are 10 standardized plans approved for sale in North Dakota. The standardized plans are identified by a letter designation of A through J.
After you are accepted by an insurance company for health insurance, the insurer must reduce any time period applicable to a pre-existing condition waiting period for time covered by qualifying previous coverage. The coverage must have been continuous for at least 63 days before the effective date of the new coverage.