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Eligibility for Health Insurance

Not having health insurance can be costly, especially if you have a medical condition that requires ongoing treatment. Many people have access to coverage at work, while others are forced to try to obtain it on the open market. A number of factors will determine your eligibility for health insurance coverage.

  1. Group Coverage

    • It is typically much easier to be eligible for a group plan, such as one provided by an employer, than to obtain coverage on the individual market. Due to the concept of "strength in numbers," a large group allows an insurance company to spread its risk among all its members, which helps it absorb the costs associated with individuals who have health issues. In general, the larger the group, the less stringent the eligibility requirements will be.

    Individual Coverage

    • If you don't have access to group coverage at work or if you're self-employed, you may have to find your own policy on the individual health insurance market. Individual insurers don't have the benefit of spreading the risk over a group of people with similar characteristics, so you will be evaluated based on personal criteria. This can make individual health insurance much harder to get, as well as much more expensive than group coverage.

    Preexisting Conditions

    • Preexisting health conditions will play a large role in determining your eligibility for insurance coverage. In a group situation, even if you are eligible for coverage, you may experience an initial waiting period, such six months or even a year, in which any preexisting conditions will not be covered if they reoccur. In the individual market, a serious preexisting condition may prevent you from obtaining coverage or your policy may be issued with a waiver that excludes coverage for the condition.

    Other Factors

    • In addition to preexisting conditions and your general health, insurers rely on a variety of other factors when determining your eligibility and premium. Two of the most important factors include your age and tobacco use, as young people and nonsmokers pay much cheaper premiums. If you work in a hazardous occupation, you may have difficulty obtaining coverage at all. Even if your own health history is favorable, a family history of conditions like cancer or heart disease may also work against you.

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