Pre-existing Conditions

Individual Health Plans and Pre-Existing Conditions

If you're a smoker, you could find yourself out of luck when looking for an individual health plan.
If you're a smoker, you could find yourself out of luck when looking for an individual health plan.
© Photographer: Oriontrail | Agency: Dreamstime

It should be noted that not every plan has to comply with HIPAA rules. In general, HIPAA rules apply to group health insurance plans. This means that individual health plans can still deny coverage based on a pre-existing condition. In these types of plans, the risk for the insurance company is greater and the cost to you is much higher.

Group health plans have the luxury of numbers, so the insurance company can handle the costs incurred by a person with a pre-existing condition. But because of the increased risk, the list of pre-existing conditions can be long.

However, there are cases in which HIPAA rules apply to individual health policies. In these cases, if you fit the requirements to be an "eligible individual," you can buy some individual health plans without a pre-existing condition exclusion. Oftentimes, these plans have significantly higher monthly premiums than a group plan, and less benefits. Therefore, this option is usually used as a last resort. To qualify as an eligible individual, you must have been covered by a group health plan for a minimum of 18 months without a 63-day break in coverage. In addition, the loss of your group coverage could not be because you failed to pay your premiums or because you committed insurance fraud. Finally, you may be considered eligible if you cannot get any other type of insurance like COBRA, Medicaid or Medicare.

In addition to HIPAA, states may have regulations on insurance plans that may ultimately benefit you. For example, some states require individual health plans to provide coverage to people regardless of their health issues. This, of course, usually results in extremely high premiums, but this might be worth it to someone who has a lot of health issues. Click here to find out your state's insurance laws.

For more information on pre-existing conditions, check out the links below. 

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More Great Links


  • CBS News: Resources on Finding Individual Health Insurance.
  • Exclusions and Limitations.
  • U.S. Department of Labor: Pre-Existing Condition Exclusion.
  • NAIC: State's Insurance Department Web Sites.
  • Tips for Buying Individual Health Coverage.