One of the trickiest areas of health insurance to understand is that of pre-existing medical conditions. In the past, it was guaranteed to exclude you from insurance coverage or cause you to pay higher fees.
The Affordable Care Act, signed into law in 2010, brought about significant changes to how pre-existing conditions impact the ability to get health coverage.
So, is a pre-existing condition still an obstacle to health insurance coverage?
We’ve compiled this guide to pre-existing conditions and how they impact your ability to get health coverage. You’ll learn what a pre-existing condition is and what it means for your insurance coverage.
You’ll also discover how to get the health insurance coverage you need, regardless of your medical history.
What Is A Pre-Existing Medical Condition?
Pre-existing health conditions are also known as pre-existing medical conditions or chronic conditions. They refer to any health issues or medical conditions an individual has been diagnosed with or received treatment for before a particular time.
This time could vary depending on the context, such as when applying for health insurance or seeking medical care. If you have an existing chronic medical condition, it’s understandable that you’d be concerned about qualifying for health coverage.
Examples Of Pre-Existing Conditions
In the world of health insurance, some of the most common pre-existing medical conditions are:
- Heart disease
- Morbid obesity
- Effects of a stroke
- High blood pressure
- Chronic Obstructive Pulmonary Disease (COPD)
- Depression or other mental disorders.
Many other chronic conditions may be considered pre-existing conditions. According to the Centers for Disease Control and Prevention (CDC), an astonishing 6 in 10 adults in the US have a chronic disease.
A pre-existing condition may be a long-term disease, temporary illness, or injury. It may be terminal, or at least life-threatening, and require chronic medication. But it can also be a manageable condition. That’s why so many people struggle to understand a pre-existing condition.
How Are Pre-Existing Conditions Determined?
When someone seeks medical care or applies for health insurance, they must provide information about their medical history, including diagnoses, treatments, surgeries, medications, and ongoing health concerns.
To determine pre-existing conditions, healthcare professionals review the individual’s medical history, evaluate their health status, and request access to their medical records from various sources.
Sometimes, a medical examination may be necessary to assess the individual’s current health status and the severity of any pre-existing conditions. This may involve physical assessments, laboratory tests, imaging studies, and other diagnostic procedures.
Based on the medical history, records, and examination results, healthcare professionals determine whether the conditions are pre-existing, their severity, and their potential impact on the individual’s health.
Insurance companies use this information to determine the coverage, premiums, and waiting periods for pre-existing conditions.
Depending on the regulations and policies in place, insurance companies may impose waiting periods before covering treatments related to pre-existing conditions.
Health Coverage And Pre-Existing Conditions Before The ACA
Before the implementation of the Affordable Care Act (ACA) in the United States, pre-existing conditions had a significant impact on an individual’s ability to get health coverage.
Insurance companies often used medical underwriting to assess an applicant’s health status, and individuals with pre-existing conditions faced challenges such as denial of coverage or higher premiums.
Denial Of Coverage
Before the ACA, insurance companies could deny coverage to individuals with pre-existing conditions.
This meant that people with serious health conditions might not be able to get any health insurance at all.
Even if individuals with pre-existing conditions could secure coverage, insurance companies could charge them significantly higher premiums. This pricing practice was called “medical underwriting,” where insurers calculated premiums based on an applicant’s health status.
Exclusions And Waiting Periods
Some insurance plans excluded coverage for specific treatments related to pre-existing conditions. Additionally, insurance policies implemented waiting periods before coverage for pre-existing conditions began.
During this waiting period, the individual would not have access to coverage for services related to their pre-existing condition. Typically, the exclusion period was 6 to 12 months.
The Affordable Care Act And Pre-Existing Conditions
The ACA significantly changed how pre-existing conditions are treated. One of the changes that the ACA introduced was that people could no longer be prevented from getting health insurance coverage due to pre-existing health conditions. This included all health plans on the ACA marketplace.
Insurers were also prevented from charging higher rates for people with these pre-existing conditions.
The ACA established a guaranteed issue provision, meaning insurance companies must offer coverage to all applicants, regardless of pre-existing conditions. Insurers cannot deny coverage or charge higher premiums based on health status or pre-existing conditions.
The ACA introduced community rating, meaning insurance companies can’t charge different premiums to individuals within the same area based on their health status. Premiums can only vary based on age, location, family size, and tobacco use.
Essential Health Benefits
The ACA mandated that insurance plans cover a set of essential health benefits, including preventive services and treatment for pre-existing conditions.
No Annual Or Lifetime Limits
The ACA prohibited insurance companies from imposing annual or lifetime limits on essential health benefits. This ensured that individuals with chronic conditions could receive ongoing care without coverage limitations.
The ACA requires insurance plans to cover certain preventive services without cost-sharing. As a result, it is easier for individuals to manage their health and prevent complications from pre-existing conditions.
Are There Any Exceptions?
The Affordable Care Act established a framework for regulating health insurance plans. While the ACA sets minimum standards for health insurance coverage, certain types of health insurance plans and exemptions may not fully comply with the law. Here are some examples.
Health insurance plans that existed on March 23, 2010, when the Affordable Care Act (ACA) was signed into law, are known as grandfathered plans. These plans are not required to adhere to certain key provisions of the ACA, such as providing coverage for pre-existing conditions without exclusions or waiting periods.
However, they can still impose annual and lifetime limits on essential health benefits. They may permanently exclude coverage for certain conditions through an “exclusionary rider.”
Another point to note is that grandfathered plans are not subject to the same restrictions on premium pricing based on pre-existing conditions as ACA-compliant plans. This means they can charge higher premiums based on an individual’s health history.
Short Term Insurance And Fixed-Indemnity Insurance
Short-term insurance and fixed-indemnity insurance are not regulated under the ACA. Therefore, they don’t have to meet ACA requirements for pre-existing condition coverage.
These plans are designed to provide temporary coverage for individuals between jobs or with other short-term needs. They typically offer limited benefits and may not cover pre-existing conditions.
My Insurance Does Not Cover Pre-Existing Conditions. What Happens Now?
If your existing health insurance policy does not cover pre-existing conditions or imposes an exclusion period, you might be without coverage for your most critical and costly medical treatments.
Your health insurance plan may follow outdated rules that predate the ACA ruling on pre-existing conditions, or it could be a type of insurance that the ACA does not regulate.
You could pay for these expenses out of pocket or with higher premiums than others. However, this will affect your access to affordable healthcare and impact your household budget in the long term.
Fortunately, there is a simple solution to get the health coverage you need. Enrolling in an ACA-compliant health insurance plan is the best option. Due to the ACA requirements, most modern health insurance plans no longer have pre-existing condition clauses.
ACA Marketplace Health Insurance
All health insurance plans on the ACA marketplace must, by law, cover pre-existing conditions. Many different insurance plans are available that comply with ACA regulations, and they all include prescription drug coverage, too.
Not sure how to go about it? We can help. Besides enrolling on the ACA marketplace at healthcare.gov or one of the state insurance exchanges, you can sign up through a licensed health insurance broker like Enhance Health.
You’ll have to meet specific eligibility criteria, but the sign-up process is quick and easy. Don’t stress if you feel you can’t afford it. ACA subsidies are available for qualifying low-income households, potentially reducing your monthly insurance premiums to zero.
Note that there is an enrolment period during which you may do so, irrespective of the platform on which you choose to sign up. This is called Open Enrollment and runs from November 1 to January 15 each year.
Specific life events may qualify you for enrollment outside the open enrollment period. Events include
- a change in the primary place of residence
- change in household size like the birth of a child, death of a spouse, or marriage.
- loss of qualifying health insurance like coverage through your employer
Alternatively, check if you qualify for Medicare coverage. Medicare is a federal social insurance program. It provides health insurance to older and/or disabled people.
Original Medicare plans cover all pre-existing health conditions. However, different parts of the Medicare system cover different needs, such as hospitalization, medical care, preventive health, hospice care, and prescription medications.
You must be 65 or older to qualify for Medicare. But you may qualify earlier than that if you have one of the following conditions:
- A serious disability
- ALS (Lou Gehrig’s disease)
- End-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant)
You can’t be signed up for ACA health insurance and Medicare simultaneously. They are two different health insurance programs. However, Medicare is subject to the same health reform regulations as ACA-compliant health insurance plans.
Different enrollment periods may apply to the various parts of the Medicare system. Need to know more about Medicare? At Enhance Health we can assess if you meet the criteria and provide information on how to enroll for Medicare health insurance coverage.
Do pre-existing conditions impact your ability to get health coverage? No. A pre-existing medical condition is no longer the barrier to health insurance coverage that it once was. Thanks to the healthcare reforms of the ACA, anyone with a pre-existing condition can now enjoy health insurance coverage.
So, if you want to say goodbye to exclusions, waiting periods, and higher rates, make the smart choice. Get yourself insured on an ACA-compliant health insurance plan.
Enhance Health has the expertise you can rely on for help choosing a plan that’s just right for you. Contact us today for more information.