Frequently Asked Questions
All the answers you need to know
What conditions are considered pre-existing conditions?
A pre-existing condition is any health problem for which you had received any medical advice, diagnosis, care, or treatment (or any recommendation to seek such care) before applying for a health insurance policy or enrolling in a new health plan.
Chronic health concerns like asthma, heart disease, cancer, and diabetes that typically require consistent, costly treatment are all considered pre-existing. Pregnancy is also considered a pre-existing condition and can therefore prevent you from adding or changing coverage after a doctor has confirmed you are expecting.
What conditions are no longer considered pre-existing conditions?
While the definition of a pre-existing condition has not changed, the rules regarding coverage of these conditions have. Prior to the passing of the Affordable Care Act (ACA), it was up to insurance companies to decide which conditions were significant enough to charge more for coverage or deny it all together. Under the ACA, health insurance companies can’t refuse to cover you or charge you more due to a pre-existing condition before or after you enroll. This rule went into effect for plan years beginning on or after January 1, 2014.
What plans (if any) don’t cover pre-existing conditions?
The current pre-existing coverage rule does not apply to “grandfathered” health insurance policies. A grandfathered policy is an individual plan you purchased for yourself or your family on or before March 23, 2010. These plans may have reduced benefits or increased costs to consumers.
What is the six-month exclusion period? When does it begin?
A pre-existing condition exclusion period is a period of time during which your insurer is not required by law to pay claims related to your pre-existing condition. Under the Affordable Care Act, the exclusion period was eliminated.
During the exclusion period, insurance companies will not cover doctor visits, prescriptions, or related treatments for any medical condition for which you have sought or received medical advice, diagnosis, care, or treatment during the 6-month period before your enrollment date. Your enrollment date is your first day of coverage or the first day of the waiting period (prior to being eligible for coverage.)
Can I ever be denied coverage because of my pre-existing condition?
Under current law, health insurance companies can’t refuse to cover you or charge you more due to a pre-existing condition. This rule went into effect for plan years beginning on or after January 1, 2014. If a new law is enacted, rules regarding coverage for pre-existing conditions may revert back to pre-ACA rules.
Before the Affordable Care Act, insurance companies were able to deny coverage for a pre-existing condition unless you could show proof of creditable coverage for at least 12 months with no gaps in coverage for more than 63 days. You could still be charged a higher premium.
How do pre-existing conditions affect riders?
Prior to the Affordable Care Act, an exclusion or impairment rider could be used to specify a medical condition that might normally be covered but isn’t because it’s a pre-existing condition. Inclusion of a rider on a policy allowed individuals to obtain coverage for other health-care needs when the excluded condition would have made them uninsurable.
-Buying Health Insurance with a Pre-existing Condition
What to do if you use Medicare?
Depending on what part of Medicare you’re enrolled in, you may or may not have coverage for pre-existing conditions.
Original Medicare. Part A and Part B do not have the same waiting period for pre-existing conditions that some Medicare Supplement plans have. Original Medicare may cover a condition your Medicare Supplement won’t.
Medicare Supplement (Medigap) Plans. These plans are offered by private insurance companies, and are specifically designed to help you pay for out-of-pocket services not covered under Original Medicare. Customizable plans pay different costs associated with copayments, coinsurance and deductibles. However, while Original Medicare doesn’t restrict coverage based on pre-existing conditions, supplemental plans may. Private insurers can turn down your application due to a pre-existing condition if you don’t apply for your supplemental plan during the 6-month Open Enrollment Period.
- You must have Original Medicare to enroll for a supplemental plan.
- The policies are guaranteed renewable even if health care issues arise.
- You can purchase a Medigap policy from any licensed insurer in your state.
- If you have had at least 6 months of continuous prior “creditable coverage,” the Medigap insurance company can’t make you wait before it covers your pre-existing condition. Many types of health care coverage can count as creditable coverage for Medigap policies, but they’ll only count if your break in coverage was no more than 63 days.
- Medigap policies must shorten any pre-existing condition waiting period by the number of months you had prior creditable coverage. For example, if you had “creditable coverage” for 2 months prior to your Medigap enrollment, the policy would apply a 4-month waiting period.
What to do if you use Medicaid?
If you’re a current recipient of Medicaid, you are automatically covered for pre-existing conditions. According to Georgetown University’s Health Policy Institute, “The Medicaid program has covered all eligible Americans who want to enroll, regardless of whether they have a pre-existing condition. And for over 50 years, the federal government has shared in the cost of caring for those individuals, whether they need medical care, long-term care services and supports, or both.”
Where do I go if my state doesn’t have its own marketplace?
People in most states will use HealthCare.gov to apply for and enroll in health coverage. According to the U.S. Department of Health & Human Services, these “health insurance companies can’t refuse to cover you or charge you more just because you have a ‘pre-existing condition’ — that is, a health problem you had before the date that new health coverage starts.”
Where do I go if my state has its own marketplace?
If your state appears on the list below, you won’t use HealthCare.gov. You’ll use your state’s website to enroll in individual/family or small business health coverage, or both. Like the plans offered by HealthCare.gov, plans offered by state marketplaces can’t refuse coverage or charge you more if you have a pre-existing condition.
Colorado-Connect for Health Colorado
Connecticut-Access Health CT
District of Columbia–DC Health Link
Idaho–Your Health Idaho (Small business employers/employees interested in SHOP coverage use HealthCare.gov)
Maryland–Maryland Health Connection
Mississippi-Use HealthCare.gov (Small business employers/employees interested in SHOP coverage use One Mississippi)
New Mexico-Use HealthCare.gov (Small business employers/employees interested in SHOP coverage use New Mexico Health Exchange)
New York–New York State of Health
Rhode Island–HealthSource RI
Utah-Use HealthCare.gov (Small business employers/employees interested in SHOP coverage use Avenue H)
Vermont–Vermont Health Connect
What to do if you get insurance through your employer?
Under Obamacare, pre-existing condition waiting periods were eliminated from all employer-sponsored health insurance plans beginning in 2014. See other ways ACA protects you as a member of an employer group plan.