Affordable Care Act
Pre-Existing Conditions: Do They Impact Your Ability to Get Health Coverage?
Updated on March 15, 2024
Share
You may anticipate having a difficult time finding suitable health insurance because of pre-existing conditions or chronic illness that you or a family member have. Though pre-existing conditions used to be a major obstacle when getting health coverage, many of those old barriers have been removed.
That said, some pre-existing conditions are more noteworthy than others from the perspective of a health insurance company. Learn more about health insurance and pre-existing condition rules, and make sure you understand what is covered and what is not.
What are pre-existing conditions?
A pre-existing condition or chronic illness is something that already existed or was treated (and was therefore listed on your medical record when you go through the process of applying for health insurance) before the effective date of your health policy.
For example, if you have been diagnosed with diabetes, it may already be on your chart when you apply for health insurance. In the past, some medical companies would balk at the prospect of paying medical expenses for someone who has already been diagnosed with a chronic medical condition.
The Affordable Care Act (ACA or “Obamacare”) prohibited pre-existing condition exclusions for all plans beginning January 2014, which was great news for all insurance beneficiaries with pre-existing conditions. In addition, Obamacare prohibited pre-existing condition exclusions for all children under the age of 19 in new policies sold on or after September 23, 2010.
Does insurance cover pre-existing conditions?
All marketplace health insurance plans must cover pre-existing conditions and cannot deny your coverage or charge you higher rates because you had a pre-existing condition.
The Health Insurance Portability and Accountability Act (HIPAA), which was passed in 1996, imposed certain conditions on when a health insurance company could exclude coverage for a pre-existing condition. As stated earlier, the ACA went one step further by prohibiting pre-existing condition exclusions for all plans since January 2014.
Are there exceptions for covering pre-existing conditions?
Today, health insurance companies are virtually banned from denying somebody coverage just because they have a pre-existing condition.
Even though these requirements should make it easier to get health insurance, there might be some exceptions for pre-existing conditions for plans that an individual was enrolled in before March 23, 2010. These are known as grandfathered insurance plans. In these cases, insurance companies can charge higher fees if you have pre-existing conditions, and they could cancel your plan under some circumstances.
In addition, if you get a short-term health insurance plan, those plans may be exempt from providing someone coverage for pre-existing conditions. That is why you should work with a professional who can help you find health insurance coverage.
What to do if your plan doesn’t cover pre-existing conditions
You may want to enroll in an ACA-compliant health insurance plan if your current insurance doesn’t cover pre-existing conditions. All plans on a health insurance marketplace must meet ACA requirements—including covering pre-existing conditions.
There’s also Medicare for those who qualify. To learn more about this option, read our post on which pre-existing conditions are covered by Medicare.
What types of plans are available that cover pre-existing conditions?
When you visit the marketplace, you will immediately see several options for coverage. They include:
- HMO plans: An HMO is a health maintenance organization. It is one of the cheapest options available for health insurance. Premiums are low, deductibles are low, and co-pays are fixed. On the other hand, you are relatively limited regarding your network size, and there is limited coverage for out-of-network visits.
- PPO plans: A preferred provider organization is typically more flexible than an HMO, but the deductibles and fees are higher. There is more out-of-network coverage, and you don’t need a referral from a primary care physician (PCP) to see a specialist.
- POS plans: A POS is a point-of-service plan that is considered somewhat of a hybrid between PPO and HMO plans. Similar to an HMO, you may be required to get a referral from your PCP to see a specialist, but you have more coverage for out-of-network doctors. You may also have to pay higher costs overall.
- EPO plans: EPO stands for exclusive provider organization. This plan only covers in-network visits, but your network is generally larger when compared to an HMO. Some plans require a referral from a PCP to see a specialist, and some do not.
Get health insurance that meets your need
Find health insurance for pre-existing conditions that fits your budget. Use eHealth to browse and compare plans based on your insurance needs. And if you need help, we have licensed insurance agents who can help you better understand your options and enroll in coverage today.