Are Your Kids Covered? What to Do if Your Child Has a Pre-Existing Condition

Under the Affordable Care Act (ACA), health insurers can no longer charge more, limit benefits, or deny coverage to you or your child because of a pre-existing health condition like asthma, diabetes, or cancer. They also cannot refuse to cover treatment for your pre-existing illness once you have coverage.

Even so, there are variables that can impact your child’s level of care if he or she has a pre-existing condition. The type of coverage you have and where you live will be factors that may impact your child’s level of coverage.

Individual Health Insurance Marketplace Coverage

Under the ACA, also known as Obamacare, children are eligible for coverage under their parents’ insurance policy until age 26. If parents are divorced, children may be enrolled under either parent, but the enrolling parent must also claim them on their current-year tax return. While children’s health insurance premiums and tax credits will be based upon parental income, parents are not required to purchase insurance for themselves in order to do so for their qualifying children.

Because these plans must comply with the rules established by the ACA, your child will be covered for any and all pre-existing conditions, and you will not be required to fulfill a waiting period or pay higher premiums because of it. He or she will also receive preventative care, dental care, and vision care at no charge and will not be subject to annual or lifetime maximums. The health policy will also include an annual out-of-pocket limit that cannot be exceeded and the option to have denied claims reviewed independently. Regardless of where you live in the United States, the same rules apply to individual and plans purchased either inside or outside the Health Insurance Marketplace.

While plans are required to cover these services, the specific policy you choose will determine the level of coverage your child receives. For example, deductible-only plans will require out-of-pocket payment of expenses for all doctor visits, prescription medications, and other treatments until the child’s individual deductible is met. These policies usually have lower monthly payments but higher out-of-pocket expenses. For this reason, many high-risk patients or those dealing with chronic illness choose plans with copayments and coinsurance. Higher premiums are offset by lower out-of-pocket costs.  

Group Health Insurance Through an Employer   

The current law states that, if you and your children are eligible for health insurance from your or your spouse’s employer, you must enroll in that company-offered plan. If both of your employers offer health coverage, eligible children can be signed up under either parent’s plan.

The good news is, many of the same coverage benefits the ACA requires for individual plans also apply to the large group plans provided by employers. Children can still be covered under a parent’s plan through the age of 26, and they will still be covered for essential services. Moreover, a child with a pre-existing condition cannot be penalized via waiting periods, exclusions, or higher premiums. Like with individual plans, the specific plan offered by your company will determine the level of benefits.


For more than 50 years, Medicaid has provided health coverage to all eligible Americans, including those with pre-existing conditions. Eligibility varies by state and is based on household income for children up to age 19. Certain circumstances may allow youth to remain covered up to age 26. All states provide comprehensive coverage to children, including the following services:

  • Routine check-ups
  • Immunizations
  • Doctor visits
  • Prescriptions
  • Dental and vision care
  • Inpatient and outpatient hospital care
  • Laboratory and X-ray services
  • Emergency services

Since the inception of the program, the federal government has shared the cost of providing this care. However, the current administration has suggested a restructuring of the Medicaid program that would cap the federal contribution to each state’s Medicaid program. If enacted, these changes would take effect in 2020, and they may disproportionately affect high-risk children like those with disabilities or pre-existing conditions.

Because states are responsible for how they decide to use available Medicaid funds, where you live may determine how much your child with a pre-existing illness is impacted by these proposed changes.

Children’s Health Insurance Program (CHIP)

The Children’s Health Insurance Program (CHIP) provides the same coverage as Medicaid, including pre-existing illnesses, but eligibility requirements differ. Typically, CHIP serves children in families with incomes too high to qualify for Medicaid, and requirements vary from state to state.

In October 2017, Congress failed to pass funding renewal for the CHIP program. While states with remaining money can continue to use it to fund the program, most states are expected to run out of money by mid-2018. If funding is not renewed, these programs could come to an end. As a result, children insured through these programs will lose coverage.

Short-Term Coverage

Short-term coverage, usually reserved for people between jobs or enrollment periods, almost always excludes pre-existing conditions for anyone on the plan, including children. While premiums are low, deductibles and out-of-pocket expenses are high. Doctor visits and prescriptions are rarely covered. These plans are designed to provide catastrophic coverage as opposed to ongoing, consistent care.