What is a Pre-Existing Condition?
A pre-existing condition refers to any illness or injury you had before enrolling in a health insurance plan. These conditions can range from chronic diseases like asthma, cancer, and heart disease to injuries or illnesses that a reasonable person could identify, even without medical treatment. For example, a hernia, an untreated injury from a fall, or a visible rash could all be considered pre-existing conditions.
Can You Be Denied Health Insurance for a Pre-Existing Condition?
As of 2014, the Affordable Care Act (ACA) made it illegal for ACA-compliant major medical plans to deny coverage or charge higher premiums based on pre-existing conditions. This policy also applies to employer-sponsored plans under HIPAA (in effect since the mid-90s), which prevents employers from discriminating against employees or their dependents due to medical history. Additionally, before 2014, many small group plans were allowed to adjust premiums based on the group’s overall medical history, but this practice was banned under the ACA.
Prior to the ACA, health insurance companies offering individual plans often required medical underwriting. They could charge higher premiums based on specific diagnoses, medications, or medical history. They were also permitted to institute waiting period, deny coverage, or stop coverage mid-year even if a member was currently in treatment for a specific medical condition.
Today, any individual plan purchased through the Healthcare Marketplace or any ACA-compliant employer group plan is required to cover pre-existing conditions fully. These plans cannot charge higher premiums or deny coverage based on your medical history. However, some employer group plans are “grandfathered,” meaning they don’t have to meet ACA standards. If you’re unsure whether your plan is ACA-compliant or how it handles pre-existing condition coverage, contact your insurance carrier for clarification.
Are There Health Plans That Still Exclude Pre-Existing Conditions?
Yes, some non-ACA-compliant plans still exclude pre-existing conditions. Short-term medical plans, Farm Bureau plans, health share programs, and other non-ACA-compliant options can impose waiting periods, deny coverage, or charge higher premiums due to pre-existing conditions. These plans may even exclude pre-existing conditions from coverage altogether, even if you’re approved for enrollment.
Similarly, supplemental insurance or indemnity plans can deny coverage or impose waiting periods for pre-existing conditions. Indemnity plans provide fixed benefits based on a diagnosis, service, or treatment, and include options like cancer, critical illness, accident, and hospital indemnity plans.
Medigap or Medicare Supplement plans may also exclude pre-existing conditions if you haven’t had continuous coverage prior to enrolling.
Why Supplemental Insurance Can Still Be an Important Part of Your Coverage
While some plans may exclude pre-existing conditions, supplemental insurance can still be a vital part of your coverage strategy. These plans are designed to cover the gaps left by major medical insurance and provide an extra layer of financial security by helping cover out-of-pocket costs like copayments, deductibles, and coinsurance. Even though your major health plan might offer robust coverage, unexpected expenses can quickly add up, making supplemental insurance an important safety net.
Additionally, some supplemental insurance policies will cover pre-existing conditions after a waiting period. This means that while coverage for certain conditions may not be immediate, you can still receive financial protection after meeting the waiting period requirements. This flexibility can make a big difference when planning for future medical needs, ensuring you’re better prepared for any unforeseen healthcare expenses.
Get Personalized Help with Your Coverage
If you’re unsure how pre-existing conditions or supplemental insurance can impact your overall coverage plan, a United Benefits Specialist can help. Our team is here to guide you through your options and find the right balance of coverage to meet your needs. Fill out the form below to schedule a free on-on-one consultation and get personalized advice for protecting your financial future.