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Inclusive Health FAQ

Frequently Asked Questions

Inclusive Health has compiled frequently asked questions and answers for your quick reference.

If you do not find an answer to your question, please contact us toll-free at  866-665-2117  866-665-2117 . We are available to take your calls Monday through Friday from 8 am to 5 pm EST.

What is the purpose of Inclusive Health?
    1. To provide access to quality non-group health care coverage to individuals whose health and/or medical history qualifies them as "high risk" and at a price that is lower than that charged to high-risk individuals by commercial health insurers.

    2. To provide insurance under North Carolina State law and the Federal Health Insurance Portability and Accountability Act (HIPAA) for eligible individuals and their dependents.

    3. To provide qualified coverage to individuals who are eligible for the tax credit for health insurance costs under the Trade Adjustment Assistance Reform Act and their dependents.

Who is eligible for coverage through Inclusive Health?
To be eligible for Inclusive Health coverage, you must meet all of the following criteria:
    1. You are a legal resident of the United States.

    2. You are a resident of the State of North Carolina.

    3. You do not have access to any other group coverage including access to coverage through a spouse or as a dependent on a parent or guardian's policy.

    4. You do not qualify for a government program such as Medicare, Medicaid, SCHIP or Social Security Disability.

    In addition, you must meet any one of the following criteria:

    1. You have been rejected or refused by an insurer for similar coverage for medical reasons.

    2. You have been offered coverage by an insurer but with conditional rider limiting coverage.

    3. You have been refused coverage except at a higher premium rate than Inclusive Health.

    4. You have similar coverage, but at a single rate higher than Inclusive Health.

    5. You have a diagnosed medical condition, outlined by Inclusive Health, which allows automatic enrollment into Inclusive Health.

    6. You are a federally-qualified, HIPAA-eligible individual, including those who currently have this coverage through an insurer. (See description of HIPAA eligible individual)

    7. You are a resident eligible for the Federal Health Coverage Tax Credit (trade- displaced workers, PBGC recipients). (See below description of HCTC)

    8. You are an eligible individual with other non-group coverage in place; you can move to Inclusive Health at any time

What is the legal residency requirement in the United States?

What is the residency requirement in North Carolina?
You must be a resident of North Carolina for at least 30 days before applying for Pool coverage. The 30-day residency requirement does not apply to HIPAA Eligibles and HCTC Eligibles; instead, residency need only be in effect as of the date of application to the pool.

What are the Medical Conditions that will automatically qualify an individual for Inclusive Health Coverage?
Acquired Immune Deficiency Syndrome/Human Immunodeficiency Virus Alzheimer's Disease Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease) Aneurysm Angina Pectoris Angioplasty Ankylosing Spondylitis Cancer (except skin) treated or diagnosed in past 5 years Cardiomyopathy Cerebral Palsy Chronic Obstructive Pulmonary Disease Chronic Renal Failure Cirrhosis of the Liver Congestive Heart Failure Coronary Occlusion Crohn's Disease Cystic Fibrosis Emphysema Hemochromatosis Hemophilia Hepatitis C Hodgkin's Disease Huntington's Chorea Leukemia Lupus Erythematosus Disseminate Major Organ Transplant Multiple or Disseminated Sclerosis Muscular Dystrophy Myasthenia Gravis Myocardial Infarction Paget's Disease Paraplegia or Quadriplegia Parkinson's Disease Polyarteritis (periarteritis nodosa) Psoriatic Arthritis Raynaud's Disease Rheumatoid Arthritis Schizophrenia Stroke (CVA) Suicide Attempt Tetralogy of Fallot Ulcerative Colitis

Who is NOT eligible for Inclusive Health coverage?
You are not eligible for coverage under Inclusive Health if:
    1. You have or obtain medical care benefits substantially similar to, or more comprehensive than, the benefit plan offered by Inclusive Health, or you would be eligible to have coverage if you elected to obtain it, except that:
      a. You may maintain other coverage for the period of time you are satisfying a pre-existing condition waiting period under Inclusive Health; and
      b. You may maintain Inclusive Health coverage for the period of time you are satisfying a pre-existing condition waiting period under another health insurance policy to replace the Inclusive Health policy.
    2. You are determined to be eligible for enrollment in Medicaid, or Medicare, unless Inclusive Health offers Medicare supplemental insurance coverage.

    3. You have previously terminated Inclusive Health coverage unless 12 months have lapsed since the termination, except that this shall not apply if you are a federally-defined eligible individual or eligible to receive benefits under the Trade Adjustment Assistance Program.

    4. You are an inmate or resident of a public institution, unless you are a federally- defined eligible individual.

    5. Your premiums are paid for or reimbursed under any government-sponsored program or by any government agency or health care provider, except as an otherwise qualifying full-time employee, or a dependent of a government agency or health care provider. This does not apply if you are receiving benefits under the Trade Adjustment Assistance Program or receiving premium subsidies made available by the State based on individual income levels, or

    6. You have other insurance coverage in place on the date that Inclusive Health takes effect.

    Coverage under Inclusive Health shall end:
      1. On the date you are no longer a resident of North Carolina.
      2. On the date you request coverage to end.

      3. Upon the death of the covered individual.

      4. On the date that state law requires cancellation of the Inclusive Health policy.

      5. At the option of the Pool, 30 days after Inclusive Health makes an inquiry concerning your eligibility or residence to which you do not reply.

      6. Failure to make premium payments, after a 31-day grace period.

      7. If the individual has performed an act or practice that constitutes fraud or made an intentional misrepresentation or material fact under the terms of the coverage.

What qualifies me as a HIPAA Federally-Defined Eligible Individual?
You are considered HIPAA-eligible if:
    1. You have a total of 18 months of creditable coverage.

    2. You have avoided a significant break in health coverage of 63 or more full days in a row. A significant break in coverage results in the individual losing credit for the coverage before the break.

    3. You do not have any medical coverage, other than that which will soon be exhausted;

    4. If COBRA, state continuation coverage, or Federal Temporary Continuation Coverage was offered, you must have accepted and exhausted it. Although an individual may apply for HIPAA coverage before the termination of COBRA, COBRA must be exhausted and then the new coverage will start.

    5. You must not be eligible for any other employment related group health coverage, Medicare or Medicaid.

    6. Your last coverage must have been through an employer or union plan (COBRA, State and Federal continuation coverage also meet this requirement) or a church plan (as defined under section 3(33) of the Employee Retirement Income Security Act of 1974.

    7. You must not have lost your last coverage through fraud or nonpayment of premiums.

    8. Generally, you must not have accepted, after losing employer group coverage, a conversion policy or policy of limited duration because they are both forms of individual coverage and will terminate your HIPAA portability rights*.

    * Please note, a person accepting a conversion policy may still be eligible for Inclusive Health coverage. For more information, please call  (866) 665-2117  (866) 665-2117 .

What is the Federal Health Coverage Tax Credit (HCTC)?
The HCTC is a tax credit of up to 80% available to individuals who qualify under the Trade Adjustment Assistance Act of 2002. The three groups of potentially eligible individuals for the HCTC are:
    PBGC Pension Benefit Recipients: you are at least 55 years old and receive a pension benefit payment from the Pension Benefit Guaranty Corporation (PBGC). You also qualify if you are at least 55 years old and currently receive PBGC benefits as a survivor, beneficiary or an alternate payee. TAA Recipients: you receive either an income supplement from your state called a Trade Readjustment Allowance (TRA) or unemployment insurance. You also either attend Trade Adjustment Assistance (TAA)-approved training or have a waiver saying you don't need training. ATAA Recipients: you are at least 50 years of age and receive benefits under the Alternative Trade Adjustment Assistance (ATAA) program.

    To be eligible for the HCTC, you must meet some general requirements. You meet these general requirements if the following statements are true for every month that you want to claim the tax credit:
      1. You are not entitled to Medicare benefits.

      2. You are not entitled to health coverage through the military health system (CHAMPUS/TRICARE). This does not include health coverage received as a Veterans Affairs (VA) benefit.

      3. You are not in prison.

      4. You cannot be claimed as a dependent on someone else's federal tax return.

Inclusive Health is a State Qualified Health Plan
In North Carolina, INCLUSIVE HEALTH is the ONLY State qualified plan by the NC Department of Insurance for high risk individuals or individuals with pre-existing conditions.

State-qualified health plan: these are plans that a state's Department of Insurance approves as meeting the requirements of the Trade Act of 2002 for the HCTC.

You must buy a state-qualified health plan directly from an insurance company or other organization designated by your state. A state-qualified health plan can be a private health insurance plan offered by a company or a public health insurance plan offered by a state. This type of plan is not available through an employer.

There may be multiple health plan options available to you in your state. You should review and compare these options to decide on the best choice for you and your family.

If you qualify for the Health Coverage Tax Credit (HCTC), beginning May 1, 2009, you are eligible to have 80% of your premium paid for. To calculate your portion of the premium, please go to Once you complete the necessary information including your age, your gender and your smoking status, your 20% share of the premium will be listed for each plan.

If you have additional questions, please call the Customer Service Center at  (866) 665-2117  (866) 665-2117 or refer to the Inclusive Health website at:
What is Creditable Coverage?
Creditable coverage is health coverage under any of the following:

Most health coverage is HIPAA creditable coverage. Creditable coverage includes prior coverage under an employer group health plan (including a governmental, church plan or a group health plan in a foreign country), health insurance coverage (either group or individual), Medicare, Medicaid, a military-sponsored health care program for members or certain former members of the uniformed services, and for their dependents, a program of the Indian Health Service, a State high risk pool, the Federal Employees Health Benefits Program, a public health plan (including any plan established or maintained by a State, the US Government, a foreign country or any political subdivision of a State, the US Government or a foreign country), a health benefit plan provided for Peace Corps members and Title XXI of the Social Security Act (State Children's Health Insurance Program).

What is a Certificate of Creditable Coverage?
Group health plans and health insurance issuers in both group and individual markets are required to furnish certificates of creditable coverage as documentation of health coverage. You may need to request this from your last insurance company and any other entities that can establish the length of coverage needed to satisfy pre-existing condition exclusions. If your prior carrier has not provided you with a certificate, other examples of proof of prior coverage can include:
    Explanation of benefits or other correspondence from a plan or issuer indicating coverage.

    Pay stubs showing a payroll deduction for health coverage.

    Health insurance identification card.

Is there a lifetime maximum under Inclusive Health coverage?
Yes. There is a lifetime maximum of $1,000,000 (One million dollars).

Are there pre-existing conditions?
Inclusive Health coverage shall exclude charges or expenses incurred during the first 12 months following the effective date of coverage for any condition for which medical advice, care or treatment was recommended or received for conditions during the 12- month period immediately preceding the effective date of coverage. If an individual enrolls in Inclusive Health during the first six months (until December 31, 2009), the pre- existing condition waiting period is six months.

Pre-existing limitations conditions do not apply to:
    A child, covered within 31 days of the child's birth, placement for adoption or placement as a foster child.

    A Federally Defined Eligible (HIPAA) Individual who has 18 months of continuous coverage or who is exhausting COBRA coverage.

    An individual that is eligible to receive the Health Coverage Tax Credit (HCTC) under the TAA, ATAA or PBGC programs.

What happens if I do not pay my premium?
Pool coverage will terminate after a 31-day grace period, retroactive to the end of the month for which the last premium was paid. If coverage is terminated for non-payment of premiums, you will not be eligible to re-apply for coverage under the Inclusive Health plan for 12 months.

Is my doctor a network provider?
The best way is to search for your physician on our providers page or to directly ask your physician if they are part of the Inclusive Health MedCost network. You can also call the Customer Service Call Center at  (866) 665-2117  (866) 665-2117 .

Is group coverage available?
No, all policies are only issued on an individual basis.

Is family/dependent coverage available?

Can my employer pay my premium?
No, employers cannot pay premium since this is not a group or an employer sponsored plan.

Can I re-apply for coverage after termination?
If you fail to pay the premium, or you voluntarily leave Inclusive Health, you will not be eligible to re-apply until 12 months after termination date, unless you are HIPAA or HCTC eligible.

Will enrollment in Inclusive Health disqualify me from eligibility for other health insurance coverage in the future?
No. Inclusive Health enrollment will not disqualify you from eligibility for other health insurance coverage in the future.

Inclusive Health is considered prior creditable coverage and in the event you leave, the program will provide a Certificate of Creditable Coverage showing your effective and termination dates. This will prove continuous coverage to a new insurance carrier and should prevent the carrier from imposing a pre-existing limitation on your new policy.

How do I find out about Risk Pools in other states?
Contact the National Association of State Comprehensive Health Insurance Pools at

What is a Health Savings Account?
An HSA works like an IRA, except that money is used to pay health care costs. Participants enroll in a high-deductible insurance plan. Then, a tax-deductible savings account is opened to cover current and future medical expenses not covered by the high deductible health plan. Up to $ 3,100 for 2009 may be deposited, and along with the earnings, are not taxable. The funds can then be withdrawn to cover qualified medical expenses tax-free. Unused balances roll over from year to year.

(Note: The annual limit on HSA deposits are set by federal law and may change from year to year. Please consult the IRS or your tax advisor to learn more about future HSA annual deposit limit modifications.)

How do I contact the Inclusive Health Customer Service?
The Inclusive Health Customer Service Department is available Monday through Friday, from 8:00 a.m. to 5:00 p.m. Eastern Standard Time.

Our toll free number is  (866) 665-2117  (866) 665-2117 .

Am I eligible for Inclusive Health coverage if I also have Medicare or Medicaid?
If you are eligible for Medicare or Medicaid, you cannot purchase Inclusive Health coverage. If you have Inclusive Health, it will terminate when you become eligible for Medicaid or Medicare.

What are some things to consider when choosing an Inclusive Health benefit plan?
How much premium can you afford to pay? See the Premium Rate Calculator to see how much the plans cost.

How much deductible would you prefer to pay each year?

How much annual out-of-pocket expense can you afford in the event you reach the maximum out-of-pocket amount?

What are your prescription drug needs?

When is coverage effective after I send in my application?
If your completed application with ALL documentation and the first month's premium is received by the 15th of the month, the effective date of the application can be as early as the first day of the month following its approval by Inclusive Health. You'll receive a confirmation letter from Inclusive Health if you are approved for coverage that will specify your effective date.

Are any other effective dates for coverage available throughout the month?
Yes. If you are exhausting your COBRA coverage, the effective date of the policy may be the day following the expiration date of the policy. Inclusive Health must receive your COMPLETE application, ALL documentation and the first month's premium 15 days prior to the effective date of coverage so that we can process your requested effective date.

Does Inclusive Health Provide any additional help with the Premiums?
Yes - beginning January 1, 2010, Inclusive Health will be offering a IH Assist and assistance with the monthly premiums based on your income and the number of members in your household. For more information and an explanation of the available discount, please see our website at A worksheet and more information is under the IH Assist" tab. You can also call the Customer Service Center at  (866) 665-2117  (866) 665-2117 for more information.

What do I have to submit to see if I am eligible for the IH Assist?
There is a separate application form for the IH Assist program which must be filled out and submitted for approval. If you are a current member, the IH Assist application and the required documentation should be submitted. If you are a new applicant, you will need to submit the completed Inclusive Health application and the IH Assist application for processing. The Inclusive Health application for coverage will have to be processed and approved before processing an application for the IH Assist may be considered.

What documentation is required for the IH Assist?
You must submit a copy of your completed 2008 tax return. Other forms of documentation include: a copy of your most recent paycheck stubs, your severance pay, your unemployment income, etc. Please see a complete description of all acceptable items in the IH Assist Premium Subsidy Application.

How can I submit my monthly premium?
Inclusive Health requires that all premiums be submitted through an Automatic Bank Withdrawal. Please see the Inclusive Health Application for more information.

How can I get a complete description of the Inclusive Health benefits?
A complete description of the benefits offered by each Inclusive Health Plan is available on the website for download. You may also call the Customer Service Center at  (888) 665-2117  (888) 665-2117 .


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