Pre-Existing Condition—What It Is & Why It’s a Big Deal

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At its most basic, a pre-existing condition is a medical condition you have before you apply for health insurance coverage. For example, if you’ve been treated for high blood pressure for a few years, when you apply for health insurance coverage with a new health plan, your new health insurance company will consider high blood pressure to be a pre-existing condition.

Why Pre-Existing Conditions Used to Be a Big Deal

Prior to the Affordable Care Act, in some instances an insurer could refuse to sell you a health insurance policy if you had a pre-existing condition.

In other instances, an insurer would exclude your pre-existing condition from your health insurance coverage. This was known as a pre-existing condition exclusion. Another possibility, the insurer might have agreed to cover your pre-existing condition, but would have charged you much higher premiums for that coverage than you would have been charged for the same coverage without a pre-existing condition.

Having a pre-existing condition like high blood pressure excluded from your health insurance coverage was a bigger deal than just having to pay for your own high blood pressure pills. The pre-existing condition exclusion could exclude more than just that single pre-existing condition from coverage. It could exclude all other conditions that developd as a result of your pre-existing condition.

For example, if your excluded pre-existing condition was high blood pressure and you had a stroke as a result of your high blood pressure, the health insurance company might refuse to pay for your stroke treatment.

  It would say that, since your stroke was a direct result of your excluded high blood pressure, the stroke was also excluded from coverage.

Pre-existing condition exclusions made it difficult for people with even simple pre-existing conditions to get health insurance coverage for reasonable premiums.

Frequently, they couldn’t get coverage at all. If they were able to get coverage, it was very expensive and excluded their pre-existing condition.

In 1996, HIPAA, the Health Insurance Portability and Accountability Act, put limitations on when health insurers were allowed to exclude pre-existing conditions and on how long a  pre-existing exclusion period could be in some instances. Learn more about this. However, pre-existing conditions were still a major problem for anyone who had been without health insurance for more than a couple of months. It was difficult to regain health insurance that would cover the pre-existing condition and any other potentially related conditions.

The Affordable Care Act and Pre-Existing Conditions

In 2014, the Affordable Care Act’s consumer protections kicked in. Now, thanks to the Affordable Care Act, health insurers in the United States can’t take your health history into account when deciding whether or not to sell you a major-medical, comprehensive health insurance policy.

They cannot exclude a pre-existing condition from coverage, nor can they charge you more because you have a pre-existing condition.

This has made it much easier for people with pre-existing conditions to buy individual health insurance, to change jobs, to retire prior to being eligible for Medicare, or to strike out on their own as an entrepreneur. People no longer have to worry that they’re one diagnosis away from being uninsurable.

Health insurance sold on the health insurance exchanges created by the Affordable Care Act is guaranteed issue, meaning a health insurance company can’t refuse to sell you health insurance coverage as long as you’re applying for that coverage during the annual open enrollment period.

When Is Open Enrollment on Health Insurance Exchanges?

When Pre-Existing Conditions Can Still Be a Big Deal

Although the Affordable Care Act made getting health insurance in the United States much easier for people with pre-existing conditions, a pre-existing condition can still cause insurance problems in some cases. Additionally, the Affordable Care Act only affects health insurance in the United States. Other countries have different rules governing the health insurance sold there. If you’re planning on living abroad and you have a pre-existing condition, how your expatriate health insurance handles your pre-existing condition will vary.

Even for those living in the United States, there are still a few times your pre-existing condition can be a big deal. Learn more about these in “3 Ways Your Pre-Existing Condition Still Causes Insurance Problems.”

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