Risk Assessment



Evaluation for Medical Underwriting

Individuals who applied for health insurance — before the Affordable Care Act was effective — who met the age, dependent, and residency criteria were subject to the Medical Underwriting Evaluation process to decide their premium costs. The following is no longer applicable for health insurance companies, as risk level is only evaluated for age and tobacco use, though coverage cannot be decline for either of those.

Risk Level Evaluation

After having reviewed all necessary medical information in detail, underwriting will do one of the following:

  • Approve the client at the regular cost of the requested plan
  • Approve the client at a higher cost for the requested plan
  • Deny the applicant benefits because of significant medical risk factors
  • Close the application due to insufficient, incomplete, or conflicting health information

 

 

Levels of Individual and Family Plan Coverage

  • Minimal Risk (all ages): Standard Premium
  • Minor Risk (all ages): Approximately 10% increase over the Standard Premium
  • Moderate Risk (all ages): Approximately 25% increase over the Standard Premium
  • Significant Risk (all ages): Approximately 50% increase over the Standard Premium
  • Severe Risk I(all ages): Approximately 75% increase over the Standard Premium
  • Severe Risk II(all ages): Approximately 100% increase over the Standard Premium
  • Severe Risk III(all ages): Approximately 125% increase over the Standard Premium
  • Severe Risk IV(all ages): Approximately 150% increase over the Standard Premium
  • Maximum Risk (under age 19): Approximately 150% increase over the Standard Premium
  • Decline Coverage (age 19 and older): Exceeds the allowable limits of acceptable Risk
  • Tobacco Risk: Applicants who currently use or have used tobacco within the past 12 months will be assigned a 25% tobacco rate. Other medical conditions, treatments, and medications will be evaluated in addition to tobacco use and may result in assignment of a higher risk level or a Decline.