Criteria for Federal Eligibility

It is frustrating that there are so many restrictions on individual health insurance that are not imposed on group health plans. This is because group health plans promise more money for coverage of several people and therefore will not lose as much for a few people with more coverage needs. Rest assured that if you have been a loyal health insurance customer in the past, you probably do qualify under federal regulations for extra protection for individual health coverage.

If you meet certain criteria, you are guaranteed the option of individual health insurance and may not be required to wait for coverage under the exclusion period. You may meet some of the criteria and not others, but in order to be eligible for this protection you must meet all of the criteria.

In your previous group health plan, you must have been given or acquired at least 18 months of creditable coverage. This is basically continuous coverage that is promised to cover you in the exclusion period that may be slapped on you with a new provider. This applies for the creditable coverage offered up to the last day of the previous plan.

If you were offered the choice of COBRA or continuation coverage from your old plan, you must have already used that benefit before you apply for additional individual health insurance.

You must not be eligible for Medicare, Medicaid or a group health plan. Remember that this rule is applicable to people who have previously paid for service of health insurance and have shown loyalty as a customer. The insurance providers believe that you should be allowed coverage on the basis that you have earned it, so to speak. Medicare and Medicaid recipients are not a valuable contribution to the company’s capital and therefore cannot be guaranteed rights besides what those programs may require.

In order to be guaranteed individual health insurance, you must not have any other health insurance under another provider or group.

If you do meet the federal requirements you must take advantage of your rights within 63 days and apply for the individual health plan within that time frame.

Once you have enrolled in an individual health insurance plan, you are not guaranteed federal eligibility any longer, as continuous coverage is only offered under a group plan. You can become federally eligible again by maintaining continuous coverage or joining another group plan.

Unique to Nevada, you are federally eligible if you were offered continuous, creditable coverage under a basic or standardized health benefit plan and the coverage ends because it is discontinued or not renewed by the insurance provider due to state regulations or reforms.