Skip to main content


Showing posts from 2008

HIPAA Versus Underwritten: Premium Issue

Hope everyone had a good Thanksgiving and we are now heading into the Christmas season.

I ran across something interesting a few weeks ago and I wanted to share it with you. It forms the basis for the order in which I help people enroll in individual & family coverage in California.

As I mentioned in an earlier blog post, CA PPO plans are able to be rated up from the standard premium in increments determined by each carrier. Some carriers offer more tiers, meaning more chances to get coverage approved.

Anthem Blue Cross (CA) Level 1 (standard), +20%, +25%, +50%, +75%, +100% (6 tiers)
Blue Shield CA Tiers 1-5 (1 being 80% of standard cost which is not always realistic) (5 tiers)
Health Net CA standard, +25%, +50% (3 tiers)
Aetna A (standard), B and C (3 tiers)

As you can see, Anthem offers the best range with 6 full tiers, Blue Shield next with 5 (as stated, Tier 1 is less than likely in the majority of cases), and Health Net and Aetna have less at 3 tiers before decline.

With all of th…

Underwriting Tip (Individual & Family California)

I wanted to address an issue with regard to underwriting for individual and family health insurance plans in California. A little tip to help you determine what plan rates to target and whether or not you would be considered for coverage.

Ignoring for a moment any health conditions that are ongoing (these are dealt with separately), we need to talk about your Rx and how it affects underwriting.

Here is a simple formula for you:

Take you monthly retail brand Rx costs and multiply them by four.

This is the minimum premium amount that you would need to target before a carrier would even consider underwriting your case.

So, let's say you have the following brand drug costs per month (you can go to drugstore dot com and get average retail pricing):

1 brand drug at $131.00
1 brand drug at $97.00
Total brand = $227.00
Minimum target premium = $908.00 (4x brand drug cost)

That means that the approximate minimum premium rate that a carrier might consider to underwrite would be over $900 per month. I…

Underwriting and Declines (Individual & Family)

I wanted to talk a bit about something that has come up quite a bit recently concerning declined coverage and health insurance underwriting in California.

I always maintian that, with the exception of MRMIP enrollments which require a decline, generating a decline unnecessarily is never a good idea. Many people have called me in the last few months who have been advised by another agent to submit an application for health insurance even though the health history appears to be problematic. This is never a good idea and is, truthfully, not necessary to determine within a reasonable degree the outcome of the underwriting.

We, as agents, are able to call into the carrier's underwriting departments and, anonymously request and underwriting "review" for any prospective applicant. In most cases, given a reasonably accurate history, that underwriter can tell us whether or not the application would be declined for coverage. Also, agents have an underwriting guideline for each…


I would like to welcome you to my California Health Insurance weblog. Unlike other insurance blogs, which are sales-oriented, the intention of this blog is to provide the reader with pertinent and important information about health plans, benefit provisions, peculiarities, underwriting, and many other topics not frequently disclosed to the public.

If you visit my web site (, you will find that I am a non-traditionalist as an independent agent. I work primarily with individuals, families, seniors and very small businesses (mostly spousal) who have difficulty in obtaining quality health insurance and may be unaware of programs available or protections under the California law.

I hope that you will find this weblog and my web site of value and I welcome feedback and comments.