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Private Health Plan Qualifications

Private plans are great options for healthy families that make too much to still save money on their premiums.

If you are paying close to full price for your Marketplace health plan, private health insurance may be a great option to help you save on your monthly premium and still get coverage for major medical expenses. They differ quite a bit from your marketplace and group health plans in that there are certain services they don't cover like prescriptions or preventative care, but the lower premiums you can get, save you in the long run.

Do I qualify?

Private health plans do have some health questions to answer to qualify and get approved. After the application, the health insurance company will run a prescription check before you get approved. Here are the qualifying questions. If you can say no to all of them, then you may qualify.

1. Is any applicant now pregnant, an expectant parent, in the process of adopting, in the process of surrogate pregnancy or undergoing infertility treatment?

2. Within the last 5 years, has any applicant received medical or surgical treatment, consulted a health care professional, or has medication been prescribed or recommended for the following:

a. Heart disorder

b. Coronary Artery Disease (CAD), Heart Attack, or a heart procedure

c. Stroke, Transient Ischemic Attack (TIA) or Carotid Artery Disease

d. Crohn’s Disease or Ulcerative Colitis

e. Liver disorders

f. Kidney disorders

g. Emphysema, Chronic Obstructive Pulmonary Disease (COPD)

h. Diabetes or Prediabetes

i. Cancer, Tumor, Lump, or Mass

j. Alcoholism, Alcohol or Chemical Dependency, or Drug or Alcohol Abuse

k. Neck or Back Disorder, Joint Replacement

l. Bipolar Disorder or Schizophrenia

m. Systemic Lupus Erythematosus or Multiple Sclerosis (MS)

3. Within the last 5 years, has any applicant received medical or surgical treatment, consulted a health care professional, or has medication been prescribed or recommended for Acquired Immune Deficiency Syndrome (AIDS) or tested positive for Human Immunodeficiency Virus (HIV)?

4. In the last 12 months, has any applicant:

a. Been recommended or scheduled for testing (excluding routine), treatment, follow-up, or surgery that has not been completed?

b. Consulted a health care professional for signs and symptoms of a medical condition for which a diagnosis has not been determined or a final diagnosis has not been communicated or determined?

You can also qualify for even lower premiums if you can answer no to some extra qualifying questions:

1. Have all adult applicants had other major medical health insurance (including Short Term) for at least 9 months within the last 12 months?

2. Has any applicant not legally resided in the US for the past 12 months?

3. Has any adult applicant used tobacco or nicotine products at any time in the last 1 year?

4. Does any adult applicant lease/own a motorcycle?

5. Has any adult applicant had any citations for DUI/DWI or more than 1 moving violation including speeding ticket(s) within the past 2 years?

6. Within the last 5 years, has any adult applicant received medical treatment or has medication been prescribed or recommended for the following:

a. High Blood Pressure or High Cholesterol

b. Anxiety or Depression

What is a pre-existing condition?

Private health plans do NOT cover any pre-existing condition. This means that if you've seen a doctor, taken a medication, had a follow up visit, had any blood work done for a certain condition, that condition and anything related to that condition will not be covered. Normally they look back 5 years, but depending on the plan it may be longer. For example, if you were diagnosed with hyperthyroidism 15 years ago and now take a daily medication for that condition and see your doctor once a year for a blood test, anything related to your thyroid condition would NOT be covered. Even though your diagnosis was 15 years ago, you were still seeing a doctor every year and taking a daily medication for that condition.

What services are not covered on private health plans?

Private health plans do NOT cover pregnancy, pre-existing conditions, prescriptions, preventative care and mental health therapy. These services you will need to pay out of your own pocket for and they will not go towards your deductible. The only exception is preventative care. Some preventative care visits and tests can go towards your deductible, but you will still need to pay for those services.

Want to see if you can get lower premiums with a private health plan?

Make an appointment with a local agent to see what these plans will cost for you. Plan pricing is based on age, network and plan length term.


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