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. Pre-existing conditions used to be an obstacle to obtaining coverage in the individual health insurance market. The ACA changed that, but the AHCA, passed by House Republicans in May 2017, could undo some of the protections granted by the ACA. 

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. This approach gained favor with insurers as time went by, simply because it was administratively easier than excluding pre-existing conditions.

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/or 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, HIPAA protections mainly applied to people seeking coverage under employer-sponsored plans.

In the individual market (coverage you buy for yourself, rather than obtaining from a job) 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, expensive, or impossible 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.

The same is also true for individual major medical coverage sold outside the exchange, which must also be ACA-compliant.

When Is Open Enrollment on Health Insurance Exchanges?

The American Health Care Act and Pre-Existing Conditions

On May 4, 2017, Republicans in the U.S. House of Representatives passed the American Health Care Act (AHCA) and sent it to the Senate. While it's likely to be significantly altered in the Senate—if it passes at all—the version that the House passed does roll back some of the pre-existing condition protections that the ACA implemented.

The initial version of the AHCA would have retained pre-existing condition protections, but the MacArthur Amendment altered the bill to allow states to waive some ACA consumer protections. Notably, states would be able to allow insurers to charge higher premiums in the individual market when an applicant has a pre-existing condition and hasn't maintained continuous coverage for the 12 months prior to enrolling int he new plan. 

The MacArthur Amendment in the AHCA also allows states to change the definition of essential health benefits, so skimpier plans could be sold. That would indirectly impact people with pre-existing conditions, as they might find that plans that include coverage for their conditions are unavailable or prohibitively expensive.

The AHCA is still far from becoming law, and the Senate version might reinstate full pre-existing condition protections. That could make it more difficult for the House and Senate to reconcile their versions of the bill, however, as the MacArthur Amendment was key to winning support from the conservative House Freedom Caucus.

Sources:

Department of Health and Human Services, Your Rights Under HIPAA.

Healthcare.gov. Read the Affordable Care Act.

House Committee on Energy and Commerce, MacArthur Amendment to H.R. 1628, Section by Section Summary.

Kaiser Family Foundation, Summary of the American Health Care Act, May 2017.

 

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