What is a Pre-Existing Condition?

A medical illness or injury that you have before you start a new health care plan may be considered a pre-existing condition. Conditions like diabetes, chronic obstructive pulmonary disease (COPD), cancer, and sleep apnea, may be examples of pre-existing health conditions. They tend to be chronic or long-term.

How are pre-existing conditions determined?

A pre-existing condition is typically when you have received treatment or diagnosis before you enrolled in a new health plan. Prior to 2010 and the passage of the Affordable Care Act (ACA), an insurance company would review your application for enrollment and if they determined you had a pre-existing condition, could deny you coverage or offer coverage at inflated rates.

The ACA made it illegal for health insurance companies to deny you medical coverage or raise rates due to a pre-existing condition.

What are some examples of pre-existing health conditions?

Chronic illnesses and medical conditions, including many forms of cancer, diabetes, lupus, epilepsy, and depression may be considered pre-existing conditions. Pregnancy before enrollment is also considered pre-existing and chronic. Other less severe conditions such as acne, asthma, anxiety, and sleep apnea may also qualify.

Can I be denied health insurance if I have a pre-existing condition?

If you are enrolled in a plan since 2010, then your insurer can’t legally deny you coverage or charge you higher premiums because you have a pre-existing condition.

The Affordable Care Act, passed in 2010, made it illegal for insurers to deny you coverage or charge high rates for pre-existing conditions. Additionally, if your health changes and you develop a chronic medical condition while enrolled in a health plan, your insurance carrier cannot raise your rates because of that medical condition. However, annual premium increases may apply to your plan for other reasons.

If, however, you are enrolled in a plan that started before 2010, you have a “grandfathered plan”. These plans can cancel your coverage or can charge you higher rates due to a pre-existing condition.

If you are exploring coverage options, it’s important to be aware of any potential changes to health care law that could impact how pre-existing conditions are covered.

Is pregnancy considered a pre-existing condition?

If you get pregnant before enrolling in a health plan, you cannot be denied coverage or charged more due to pregnancy. Coverage for pregnancy and delivery begins from the day you enroll in a plan.

Is there health insurance for pre-existing conditions?

Choosing a health plan is no longer based on the concept of a pre-existing condition. A health insurer cannot deny you coverage or raise rates for plans if you have a medical condition at the time of enrollment. However, there may be health plans that are a better fit for you than others if you have a chronic, or pre-existing, medical condition.

For example, if you need regular medical care, surgeries, or treatments, then a plan with a little higher monthly premium and lower deductible may provide you with the coverage you need and help you manage more predictable costs.

Could my health plan have a pre-existing condition waiting period?

No. There are no waiting periods for medical plans, including for pre-existing conditions.

When choosing a health plan, consider your medical needs. If you have a chronic or ongoing medical condition that requires more frequent care, those needs could affect the type of plan you choose, but you cannot be denied coverage or charged more due to a pre-existing condition.