Pre-Existing Conditions


A pre-existing condition is defined as a condition you received treatment for or were diagnosed with before enrolling in health insurance. Under the health reform law, pre-existing conditions are no longer a factor in determining health plan eligibility or rates. Prior to the law, health status and medical history affected your ability to get covered or pay a fair premium. Pre-existing conditions could range from cancer to pregnancy, making it difficult for many people to get insured on the individual market especially. On the group market, a pre-existing condition typically caused every insured worker’s rates to increase, which is not permitted under Obamacare.

Before the law took effect, each state was allowed a look-back period, or the window of time each insurer could check for all of your health problems. These could be as short as six months in states with a maximum look-back period, or any length in states without a limit. Presently, no look-back periods are applicable, as you will be accepted for coverage regardless of your health.


Exclusion Periods

Prior to health care reform, individuals with a pre-existing condition could be denied or charged more for health insurance. The Affordable Care Act has changed this so that the people who need coverage can receive it. Exclusion periods were frequently used by health insurance companies to avoid paying for costly recurring treatments related to pre-existing conditions.

When an insurer issued an exclusion period for a sick plan member, the patient had to pay for all medical care related to their condition out-of-pocket, until the exclusion period ended. Exclusion periods usually lasted from six months to two years, but in some states, insurers were allowed to make them permanent. If an insurance company decided to make your exclusion period permanent, they would attach an elimination rider to the policy and never have to cover that type of care. Each of these actions is prohibited by the ACA and no longer apply.


Pre-Existing Conditions and Health Reform

A substantial provision of the Affordable Care Act addresses the equal treatment of those with pre-existing conditions. From 2010-2013, insurance companies could not deny coverage to children with pre-existing conditions, but adults had to join the temporary high-risk pool and wait until 2014 to get covered. To qualify for the risk pool, PCIP, applicants must have been without insurance for at least six months and they must have proof of rejection from an insurer.

Now that the risk pool is unnecessary, people who have what would have qualified as a pre-existing condition — whether acne or HIV — can apply with any insurer they choose. The law also developed the health insurance marketplace in each state, which connects people to comprehensive coverage though private companies competing for your business. Exchanges are also an advantage for low- to moderate-income households, as many Americans qualify for tax credits to lower premiums and medical costs. These plans include various types of coverage and never discriminate against health problems.

Also, the ACA made it illegal to cancel existing coverage based on being diagnosed with a pre-existing condition while you’re already insured. Your coverage can only be cancelled if you lied on your application or omitted information intentionally. This is considered fraud and will be penalized. The insurance company is required to inform you when they terminate your benefits, so you won’t be in the dark and possibly have enough time to find a new plan.