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What Is A Pre-existing Health Condition?

What a Pre-existing Condition Means for Your Health Insurance

Key Takeaways

  • A pre-existing condition is a health issue that you have before a given health insurance policy starts.

  • The Affordable Care Act (ACA)The Affordable Care Act is a healthcare reform bill from 2010 aimed at reducing the amount of uninsured Americans by making coverage more affordable. Also known as The Patient Protection and Affordable Care Act, the ACA requires insurance companies to cover preventive care and other essential health benefits. Also known as "Obamacare." prohibits health plans from denying coverage to people with pre-existing conditions or charging more for premiumsA premium is a fee you pay to your insurance company for a health plan coverage. This is usually a monthly cost..

A physician reviews a patient's medical history.

What is a pre-existing condition?

A pre-existing condition is a health condition that exists before a health insurance policy begins. Conditions include diabetes, cancer, asthma, sleep apnea, lupus, depression, high blood pressure, among many other life-threatening illnesses and chronic diseases. At least 50 million Americans [1] have some sort of pre-existing condition. Additionally, 25% of adults [2] have two or more chronic health conditions.

As protection under the Affordable Care Act (ACA), insurance companies cannot change your coverage or increase costs based on previous health or medical conditions. If you have pre-existing conditions, you can shop for coverage during open enrollment and apply for the health plan you want.

Can I still get coverage with a pre-existing condition?

Yes, you can still get coverage with a pre-existing condition. Health insurance companies cannot deny coverage for medical conditions you had before enrolling in a plan. They also cannot limit benefits or raise premium costs.

This protection law was passed in 2010 as part of the ACA and went into effect for plans beginning January 1, 2014. [3]  Previously, insurance companies could refuse to cover pre-existing conditions, making it difficult for those with previous health conditions to find an insurance plan.

There is one exception: grandfathered individual health plans. If your current policy started before March 23, 2010, it does not have to cover a pre-existing condition, and your rates can increase. Consider a new Health Insurance Marketplace plan if this affects you.

How are pre-existing conditions determined?

Insurance companies evaluate your current health status when you apply for coverage. Insurers look at your medical history for treatments or diagnoses of chronic conditions.

Before 2014, health insurance companies could implement a pre-existing exclusion period, or a waiting period, before you could receive coverage relating to a pre-existing condition. Now, many insurers cannot use the exclusion period.

Commonly excluded pre-existing conditions before the ACA: [4]

  • Alzheimer’s Disease
  • Certain Cancers
  • Congestive Heart Failure
  • Cerebral palsy
  • Diabetes
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Pregnancy
  • Stroke
  • Among others

Is pregnancy a pre-existing condition?

Pregnancy is not considered a pre-existing condition. [5] Insurance companies may not reject coverage for your pregnancy or childbirth. If you have a baby or adopt after open enrollment, you can qualify for the Special Enrollment Period because it’s considered a life-changing event.

What should I consider when looking for coverage if I have a pre-existing condition?

Although an insurer can’t refuse coverage, it’s essential to consider your options. There may be health plans that match your needs better if you have chronic or pre-existing conditions.

Here’s a checklist of what to consider before applying for a plan:

  • Prescription Drugs: Does your plan have a list of medications that your health plan covers? Knowing this information could help you determine how much your prescriptions will cost and how much coverage you will need.
  • Chronic Care Management: Some insurance plans cover care management for chronic conditions such as arthritis, asthma, diabetes, mental health, and other diseases. Medicare may help cover the costs of chronic care management services if you have two or more severe conditions.
  • Doctor visit: Do you visit the doctor’s office often? Check to see if your providers are in-network with the plan you’re considering.


Can Medicare deny coverage for pre-existing conditions?

Medicare generally covers pre-existing conditions, but there are some exceptions.

Medicare Supplement plans [6]
During your six-month Medigap Open Enrollment Period, insurance companies cannot deny coverage or charge more if you have pre-existing conditions. However, you may be subject to medical underwriting after that period. Insurance companies use medical underwriting to determine your health status and how much your policy will cost. There’s also a chance your application won’t be accepted if you don’t meet the minimum health requirements.

End-Stage Renal Disease (ESRD)
Medicare beneficiaries with end-stage renal disease may not be able to buy a Medigap policy [7] until age 65. You also cannot enroll in a Medicare Advantage [8] plan unless:

  • You have a Medicare Advantage plan when diagnosed with ESRD
  • Your current plan drops Medicare or is unavailable in your area
  • You no longer have ESRD

It’s important to note there will not be any restrictions to enroll in Medicare Advantage with ESRD starting 2021.

Will my premiums be higher if I’m overweight?

Enrollees who are overweight or obese will not be charged more for health insurance coverage. People who are obese will be able to take advantage of wellness and nutrition programs provided by new health plans.

Does tobacco use affect my health insurance costs?

Health insurers are allowed to charge people more if they smoke or use tobacco. The prices can be steep depending on which state you live in, so it could pay off to kick the habit before enrolling in a health plan.

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