Pre-Existing Condition: What it is, How It Applies to Insurance


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When the Affordable Care Act (ACA) went into effect in 2010, the term “pre-existing condition” was frequently tossed around. “We are now actually able to provide some help to the American people,” President Barack Obama said in a 2010 visit to Virginia. During his speech he referred to a woman with non-Hodgkin’s lymphoma who was now able to benefit from the rule change for pre-existing conditions. But those unfamiliar with health insurance policies may not understand what a pre-existing condition is, how it relates to health insurance, and why the ACA was so groundbreaking for people with pre-existing conditions. 

What is a pre-existing condition?

A pre-existing condition is a health condition that you are diagnosed or treated for before signing up for a new health plan. Pre-existing conditions tend to be chronic, long-term illnesses and medical conditions. They range from severe diseases to less serious issues like a broken arm. Some examples of pre-existing conditions include various types of cancer, diabetes, epilepsy, and depression. Pregnancy, acne, anxiety, allergies, high blood pressure, sleep apnea, asthma, and other lung diseases may also be considered pre-existing conditions. Around 130 million Americans have what insurers consider to be a pre-existing condition. You can even be denied health coverage if a pre-existing condition is in your family history. For instance, if your parent has high blood pressure, an insurance carrier could see that as a reason to deny you protection or force you to pay more. 

Women are also disproportionately impacted by pre-existing conditions. Many medical conditions women experience like pregnancy, breast cancer, and irregular menstruation are identified as pre-existing conditions by insurers. 

Insurance companies use two definitions when classifying pre-existing conditions. The “objective standard definition” denotes a pre-existing condition as any health condition in which the individual received medical advice or treatment before enrolling in a new plan. The “prudent person” definition comprises a wider scope of medical history and treatment.  For this definition, a pre-existing condition could be anything in which symptoms were present and a “prudent person” would seek treatment for. 

How does it apply to health insurance?

Before the ACA or Obamacare was passed, getting health insurance with a pre-existing condition was difficult. Health insurance companies could deny an individual with a pre-existing condition insurance, offer them coverage at increased rates, or restrict benefits. The passage of the ACA made it illegal for health insurance companies to deny individuals with a pre-existing condition coverage or charge higher rates. If you develop a chronic medical condition while enrolled in a plan, your health insurer cannot increase your rates. Additionally, Medicaid and the Children’s Health Insurance Program cannot reject you coverage or charge you inflated rates due to a pre-existing condition. 

But if you are enrolled in a health plan before the legislation was passed in 2010, then you are part of what is called a “grandfathered plan.” This means your insurance carrier can charge higher premiums or cancel your protection because of a pre-existing condition.  If you are enrolled in a grandfathered plan, you have two options to help cover your pre-existing conditions. You could switch to a Marketplace plan, which will cover your pre-existing condition during Open Enrollment. Or you could purchase a Marketplace plan outside of Open Enrollment when your grandfathered plan year ends. In this circumstance, you will qualify for a Special Enrollment Period. If you have questions regarding your health insurance options, seek assistance from New York philanthropist and lawyer Howard Fensterman, who specializes in healthcare law. 

The political climate in the United States is fraught with division and ideological differences, but there is one thing Americans can agree on: coverage for pre-existing conditions. Currently, more than 70 percent of the population wants protections for patients with pre-existing conditions preserved.