Navigating health insurance options when you have pre-existing medical conditions can be challenging. It’s crucial to understand how different health insurance plans cover these conditions. Recent changes in healthcare laws have made it easier for individuals with pre-existing conditions to get coverage. This summary will explore how health insurance for pre-existing conditions works, including the protections and options available under various health insurance plans, ensuring you have the information needed to make informed decisions about your healthcare coverage.

What are pre-existing conditions?

According to the Centers of Medicare and Medicaid Services (CMS) 50 to 129 million non-elderly Americans have some type of pre-existing health condition. As the Patient Advocate Foundation notes, a pre-existing condition is a health condition, illness, or injury that you know about—perhaps even have received or have scheduled treatment—before applying for health insurance coverage.

Some examples of pre-existing conditions include:

• Pregnancy
• Epilepsy
• Asthma
• Sleep apnea
• Cancer
• Diabetes

Pre-existing conditions, of course, are not limited to these few examples, and you should make sure to read the specifics of any plan you’re considering making sure that your plan covers any medical conditions or health problems you have.

Insurance companies used to sometimes charge more or refuse people with pre-existing conditions. This is because more health problems will result in a high-risk pool of members—which means the insurance company was dishing out more money for people who actually used their individual health insurance to its fullest extent.

The impact of pre-existing conditions on health insurance

The impact of pre-existing conditions on health insurance is significant, particularly in how these conditions affect eligibility and premium costs. Firstly, thanks to the Affordable Care Act (ACA), insurers can no longer deny coverage or charge higher premiums based solely on pre-existing conditions. This has dramatically increased access to health insurance for individuals with chronic health issues. Secondly, the type and severity of a pre-existing condition can influence the level of healthcare services required, potentially leading to higher overall healthcare usage and costs. This makes choosing the right plan with adequate coverage essential. Lastly, for employer-sponsored plans, coverage of pre-existing conditions is generally immediate, whereas some individual plans might have specific terms regarding the coverage start date for these conditions. Understanding these impacts is crucial for anyone with pre-existing health issues seeking health insurance.

Changes due to the Affordable Care Act (ACA)

You can get health insurance if you or a family member has a pre-existing condition. However, prior to the implementation of the Affordable Care Act (ACA), it was nearly impossible for individuals to obtain health insurance with pre-existing conditions. This has not always been the case. 

Prior to the 2010 passage of the Affordable Care Act (also known as “ACA” and Obamacare), insurance companies could refuse coverage for the pre-existing condition(s), charge significantly higher premiums to insure people with pre-existing conditions, or reject the applications for health insurance from people with pre-existing conditions. This was because insurance companies were paying astronomical amounts for healthcare for individuals with pre-existing conditions, and since they weren’t required to accept all applicants, they began determining what pre-existing conditions are not covered.  Pre-existing conditions posed sometimes insurmountable barriers to changing jobs, changing health insurance, and finding affordable care. But that is largely a problem of the past.

Not only was the Affordable Care Act passed in order to give people access to affordable healthcare coverage, but it was also passed to protect people with pre-existing conditions. These individuals can no longer be denied coverage, and if you’re wondering whether an insurer can charge more for pre-existing conditions, then the answer is “no,” although other conditions (e.g., age, where you live, how many people in your family require coverage, which specific plan you choose), can affect your rates. 

Essential health benefits and pre-existing conditions

Under the Affordable Care Act (ACA), all health insurance plans offered in the individual and small group markets, both inside and outside the ACA Marketplaces, are required to cover a set of 10 essential health benefits including services like:

• outpatient care
• emergency services
• hospitalization
• maternity and newborn care
• mental health and substance use disorder services
• prescription drugs
• rehabilitative services
• laboratory services
• preventive and wellness services
• pediatric services

This comprehensive coverage is particularly beneficial for individuals with pre-existing conditions, as it ensures they have access to a wide range of necessary medical services. Regardless of their health history, policyholders are guaranteed coverage for these essential benefits, which helps in managing chronic conditions, obtaining necessary medications, and accessing preventive care to maintain their health. The inclusion of these benefits in all ACA-compliant plans represents a significant step in providing equitable healthcare access to individuals with pre-existing conditions.

Guaranteed issue and pre-existing conditions

The concept of “guaranteed issue” in health insurance refers to the requirement that health insurance providers must offer coverage to any applicant, regardless of their health status, age, gender, or other factors. This means that individuals cannot be denied insurance coverage due to pre-existing conditions. Under the Affordable Care Act (ACA), guaranteed issue is a fundamental provision that ensures individuals with existing health issues have the same access to insurance as those without such conditions. This policy represents a significant shift from previous practices where insurers could deny coverage or charge higher premiums based on an individual’s health history. Guaranteed issue has thus played a crucial role in enhancing access to healthcare for everyone, particularly those with chronic illnesses or ongoing health needs.

Understanding waiting periods

Depending on the specific medical plan that you end up purchasing, there could be a waiting period before pre-existing conditions are covered. This period could be anywhere from 12-18 months, meaning that if you receive treatment for your condition prior to this period having passed, then you must pay for costs out-of-pocket. To understand the specifics of your plan, contact your health insurance provider.

High risk pools and alternative options

High-risk pools were state-run health insurance programs designed to provide coverage to individuals who were denied health insurance due to pre-existing conditions, or who faced exorbitantly high premiums. Prior to the Affordable Care Act (ACA), these pools served as a safety net for those considered “high risk.” However, they often came with limitations such as high costs, caps on enrollment, and limited coverage.

Post-ACA, the need for high-risk pools has largely diminished since the law mandates that insurers cannot deny coverage or charge higher premiums based on pre-existing conditions. This means individuals previously relegated to high-risk pools now have broader options for coverage.

For those who still find themselves struggling to afford health insurance, even with these protections, alternative options include:

1. Medicaid: Depending on income and state-specific eligibility criteria, Medicaid can be a viable option for affordable health insurance.
2. Subsidized Plans through ACA Marketplaces: Based on income, individuals may qualify for subsidies to lower the cost of premiums and out-of-pocket expenses on plans purchased through ACA marketplaces.
3. Catastrophic Health Plans: Available to people under 30 and to some low-income people who are exempt from other ACA plans, these plans cover essential health benefits but have a high deductible.
4. Community Health Centers: For uninsured individuals, these centers provide health services on a sliding fee scale based on income, offering an alternative for primary care and other medical services.

It’s important for those in high-risk categories to explore these options and consider the expanded protections and choices available under current healthcare laws.

State-specific regulations

State-specific regulations can significantly impact health insurance policies, rules, and the application process. While the Affordable Care Act (ACA) has standardized many aspects of health insurance coverage across the U.S., individual states still retain the power to implement additional regulations that can affect insurance plans within their borders.

1. Medicaid Expansion: One of the most significant differences lies in Medicaid expansion. States like California, New York, and Illinois have expanded Medicaid under the ACA, providing broader coverage for low-income residents. In contrast, states like Texas and Florida have not expanded Medicaid, affecting coverage options for residents in these states.
2. State-Run Marketplaces: Some states, such as California, Colorado, and Massachusetts, operate their own health insurance marketplaces. These state-run marketplaces may have different enrollment periods and additional state-specific health plans, unlike states that use the federal marketplace.
3. Insurance Mandates: States like Massachusetts have individual health insurance mandates, requiring residents to have health insurance or face a tax penalty, which is not a requirement in most other states.
4. Additional Benefits: Certain states may mandate additional benefits beyond the federal ACA requirements. For instance, some states require health insurance plans to cover specific types of healthcare services or medications that might not be mandatory under federal law.
5. High-Risk Pools: Before the ACA, states like Minnesota and Wisconsin had high-risk pools for individuals with pre-existing conditions. Though less relevant now due to the ACA’s provisions, these programs’ legacies may still influence current health insurance frameworks in these states.

Given these variations, it’s essential for consumers to understand their state’s specific health insurance regulations and options. Consulting state-specific resources or speaking with local health insurance navigators can provide clarity and guidance tailored to the unique healthcare landscape of each state.

Applying for health insurance with a pre-existing condition

If you have a pre-existing condition, then it’s important that you take your time when switching to or choosing insurance with a pre-existing condition to find the best medical insurance. If you fail to find the best health insurance plan for your pre-existing condition, then you could end up being denied coverage for your illness and must pay substantial amounts out of pocket. 

Aligning your search with open enrollment periods is crucial if choosing a plan through the ACA marketplace, typically from November 1st to December 15th, or during employer-specific enrollment periods for job-based insurance. Starting early is key to avoiding coverage gaps or high out-of-pocket expenses, ensuring you find the best insurance plan for your healthcare needs.

It’s easy to find health insurance with a pre-existing condition. ACA-compliant health insurance is available from your state’s marketplace and off the marketplace. Let eHealth help you find the plan that is right for you. You can start your search now by checking out all the individual and family health insurance plans available in your area. Simply answer a few questions about your health insurance needs and select Find ACA Plans. The eHealth plan search tool will identify the plans available where you live and permit you to compare costs and benefits. Our health insurance brokers and agents are available to assist you as well. At eHealth, our goal is to help you find effective health coverage at an affordable price—regardless of your current health condition.

Watch outs and exceptions in health insurance for pre-existing conditions

Watch out for these types of health insurance plans if you have pre-existing conditions.

If you or a family member has a pre-existing condition, you should be aware of the two main exceptions in which health insurers may not cover pre-existing conditions.

1. Short-term medical policies. Short-term medical policies might not cover you due to preexisting health conditions like diabetes, cancer, stroke, arthritis, heart disease, mental health & substance use disorders. Even short-term medical insurers that accept your application may impose a wait period before they will cover treatment related to a pre-existing condition. A short-term medical policy  may be in effect for 3 months and may renew up to one additional month. Given its short duration, a short-term policy might not help you pay for treatment of pre-existing conditions even if the insurer accepted your application. However, these plans don’t have to meet Federal standards for comprehensive health coverage.
2. Grandfathered group health plans. If you can obtain coverage for yourself or a family member with a pre-existing condition under an employer’s or union’s group health coverage, be sure to check first with the plan administrator to see if the plan is “grandfathered.” Grandfathered plans are health plans that were in place before March 23, 2010. By law, these health plans can offer the same benefits today they offered before the Affordable Care Act. They may restrict or exclude coverage for pre-existing conditions.

Frequently asked questions about health insurance and pre-existing conditions

Pregnancy as a pre-existing condition

In some cases, individuals may be confused about whether pregnancy is a pre-existing condition. Pregnancy is a pre-existing condition, but it’s not treated in the same way as other illnesses. Your insurance premium will not be increased, nor will you be denied maternity coverage if you become pregnant prior to seeking insurance. 

Will a pre-existing condition result in a higher premium?

Under current law, insurance companies cannot charge higher premiums or refuse health insurance coverage due to pre-existing conditions. If you’re buying an ACA-compliant individual health insurance plan, you won’t have to worry that health insurance is out of reach because of pre-existing conditions you or a family member may have. You still need to compare health insurance plans’ costs and coverages, however, to make sure you are choosing health plan coverage that best meets the needs of you and your family.

A licensed eHealth insurance agent is available to help you understand your health insurance options and identify plans that are likely to result in the affordable care you and your family need.

Can I get Medicaid and CHIP coverage with pre-existing conditions?

The ACA has also made it impossible for Medicaid and CHIP programs to deny coverage to individuals with pre-existing conditions. 

As a result, as long as you’re able to qualify for these programs, you can receive coverage for your chronic conditions from the very first day. Plans purchased through the Marketplace offer the best medical insurance for pre-existing conditions, and if your income is low enough, Medicaid and CHIP do, as well.

Short-Term Notice 2024