Your Right to Obtain Health Insurance in Virginia

Health insurance is almost entirely regulated by the states, and the rules and regulations governing it vary widely from one state to another, permitting or disallowing barriers to access.  It is important to understand how health insurance functions in your state in order to evaluate what types of reform are needed, both on the state and federal level, to make quality, affordable health insurance available to everyone.

Your rights to obtain health insurance in Virginia vary depending on whether you purchase insurance as an individual, under a group plan, or as a small business owner.

Getting health insurance as an individual in the open market
If you are not insured through your employer, union, or some other type of group, you are currently not guaranteed the right to buy health insurance in Virginia. Private insurers can refuse to sell you insurance because of your health status, or exclude a pre-existing condition from coverage, or charge you a higher premium based on your age, gender, or pre-existing medical condition. For those accepted by a plan, the premium (monthly payment) will be determined by several factors, the most important of which is age: a person in their fifties may pay hundreds of dollars more per month than a person in their twenties for the same benefits.  If you had a break in insurance coverage of 63 days or more, you may face a pre-existing condition exclusion period. Insurers define pre-existing conditions as those for which you received medical advice in the past 12 months. The amount of time you were covered under your previous insurer may be credited toward your pre-existing condition exclusion period if you have not had a break in coverage of 63 days or more.  This can cancel out or reduce the length of a pre-existing condition exclusion period. Coverage for pre-existing conditions can be excluded for a maximum of 12 months. Insurers can also impose an elimination rider, which permanently excludes coverage of a health condition and/or entire body system, regardless of your medical history.

COBRA is a law that lets you keep the insurance you had through your job if your employer has 20 or more employees. COBRA coverage lasts up to 18 months (sometimes longer) after you’ve left or become ineligible for benefits. You will pay the full premium, i.e. both your share and the amount your employer or union was paying on your behalf. COBRA can be quite expensive, but may be cheaper than buying an individual policy on the open market.

You may also be eligible to buy an insurer's HIPAA plan. All licensed insurance carriers are required to sell HIPAA plans in Virginia. HIPAA is a law that guarantees you access to insurance coverage if: 1) you had at least 18 months of continuous insurance coverage, the last day of which was under a group plan, 2) you have exhausted any COBRA coverage which was available to you, and 3) you are not eligible for any public or group health plans. No pre-existing condition exclusion periods can be imposed.

In the case of an emergency, federal law protects you from being denied care in an emergency room, regardless of your insurance status or ability to pay. If you do not have health insurance and it’s not an emergency, hospitals are not required to treat you. However, some hospitals will anyway. In addition, some have charity care programs which set fees based on income for those who are uninsured.

Getting insurance through a group or small business
If you are insured through your employer, union, or some other type of group, you cannot be denied insurance because of your medical history. Insurers can however count as pre-existing conditions those for which you received medical advice in the 6 months prior to the start of your policy. If you had a break in insurance coverage of 63 days or more, you may face a pre-existing condition exclusion period. Coverage for pre-existing conditions can be excluded for a maximum of 12 months. You can get credit for prior coverage if you do not have a lapse in coverage of 63 days or more. This can cancel out or reduce the length of a pre-existing condition exclusion period.

For more information on getting and keeping health insurance, please visit www.ahirc.org.