Individual Ohio Health Insurance Regulations

In the state of Ohio, individual health insurance is not guaranteed issue. Insurers have the right to decline coverage for any reason. Typically, a denial of an application takes places if the applicant has a pre-existing medical condition viewed as high-risk by the insurance provider.

During January of each year, insurers are required by Ohio law to accept all applications on a guaranteed issue basis until the companies' enrollment cap has been achieved. The guaranteed issue plans available are limited to one basic plan and one standard plan. An Ohio state board regulates the basic requirements of these two medical insurance plans. The standard health insurance plan in Ohio is characterized by a lifetime maximum of $1 million with a yearly deductible of $750. An individual may only submit an application for one of the guaranteed issue plans if he or she is ineligible for an employer's group health insurance plan.

Except for these two standardized health insurance plans in Ohio, all other policies offered by insurance providers go through the medical underwriting process at all times during the year. Insurers have the legal right to place elimination riders on new plans which protect them from having to pay toward benefits of specific pre-existing conditions. If the insurer does not impose an elimination rider on a certain condition, the provider may still reserve the right to avoid paying benefits on the condition or list of conditions for up to one year.

An insurance applicant with prior creditable health insurance coverage will likely be able to have the exclusionary period reduced. Insurers in Ohio have the right to review an applicant's medical history for six months prior to the application. If a consumer chooses an Ohio HMO health insurance plan, insurers may not place exclusionary periods for basic health care services.

Ohio Small Group Health Insurance Regulations

When an employer has from two to 50 employees, it qualifies for small group health insurance in Ohio. These health plans are guaranteed issue, meaning the group's application cannot be declined due to the current or past health status as a group or due to an individual in the group. Also, the small group health insurance plans are guaranteed renewable. Insurers may not cancel or deny renewal even if there are an increase in claims and medical costs for the group.

It is possible that insurers will require that the employer enroll a minimum percentage of all eligible employees in the small group health plan. Although the insurance provider may use medical underwriting to determine premiums, it may not deny coverage for any individual employee based on health status. Small group premiums may not be higher than 35% of the standard rate.

Understanding Ohio COBRA and Continuation Coverage Issues

An Ohio employer with more than 20 employees falls under federal COBRA regulations. There is also a part of the Ohio COBRA which applies to companies having fewer than 20 employees. COBRA states that if an employee experiences a qualifying event, he or she must have the opportunity to continue group health insurance plan coverage in Ohio.

Qualifications and guidelines for Ohio COBRA for groups under and over 20 employees include:

• Employee received coverage under a group plan for a minimum of one year prior to the termination date.
• Employee verifies in writing the desire to utilize the COBRA option within 31 days of receiving their notification of COBRA rights.
• Continued COBRA coverage is capped out at 18 months for employees, whereas and employee's spouse and dependent children have 36 months of the continued coverage.
• Employees coming from a group with under 20 employees may use COBRA to remain with group plan for a period of six months, as long as they have been insured under the employer group plan for a minimum of three years prior to their termination date.
• Businesses that continue to insure employees under Ohio's COBRA regulations have the right to exclude some benefits from the policy, but are required to provide coverage for hospitalization and major medical care.
• Employees who choose to continue coverage under COBRA are responsible for premium payments.
• Employees who voluntarily leave the place of employment are ineligible for COBRA.

After an employee has used all of the time available for COBRA coverage, they qualify for guarantee issue coverage through other private individual health insurance companies. In Ohio, these insurers are required to offer a basic or standard plan to people who qualify through HIPPA. There are also conversion plans available through most insurance companies.

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