A pre-existing condition refers to an illness, injury, or other medical condition you have been diagnosed with — or have shown symptoms of — before you purchase a health insurance policy.
Pre-existing conditions are common: More than 129 million Americans under 65 may have a pre-existing condition, which amounts to almost half of the population. Older Americans are at greater risk; between 48% to 86% of those aged 55 to 64 have at least one pre-existing condition. These conditions may be life-threatening or chronic, simple or complex, and can play a role in your insurance coverage.
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Prior to January 1, 2014, insurance companies could deny coverage to individuals with pre-existing conditions. Under the ACA, however, insurance companies cannot use pre-existing conditions to deny coverage, charge more for services, or refuse to pay for essential health benefits. However, these conditions may still affect the cost of health insurance. With 20% of non-elderly Americans who have pre-existing conditions uninsured and possibly at risk of paying significant amounts out-of-pocket, it’s worth taking the time to find healthcare insurance options that both meet your needs and stay within your budget.
How Are Pre-existing Conditions Determined?
Pre-existing conditions may be determined in several ways. First is self-reporting by individuals who know or suspect that they have a pre-existing condition. It’s also possible that a medical examination prior to the start of health insurance coverage may reveal an unknown pre-existing condition. For example, an insured person might report sporadic leg or chest pain that upon further investigation is revealed to be cancer, making it a pre-existing condition.
In some cases, pre-existing conditions may not be detected for months or years after insurance coverage starts. This might be the case if individuals present no symptoms when they apply for insurance, but during a later checkup, doctors discover a latent illness or a disease that has been slowly advancing over time.
What Are Examples of Pre-existing Conditions?
Pre-existing health conditions can take many forms. They may be something you’ve had since childhood or develop later in life. Some common pre-existing conditions include:
- Asthma
- Sleep apnea
- Depression
- Anxiety
- Cancer
- Diabetes
- Alzheimer’s disease
- Kidney disease
- Congestive heart failure
- Coronary artery disease
- Liver disease
- High blood pressure
- Stroke
- Epilepsy
- HIV/AIDS
You may also have a less common pre-existing condition, such as Huntington’s disease, acquired hemophilia, Baller-Gerold syndrome, or Caroli Disease. Common or rare, your pre-existing condition is covered under your health insurance.
Will My Health Insurance Cover Pregnancy?
Health insurance will cover pregnancy. Under the ACA, expecting mothers cannot be denied coverage. Prior to the ACA, pregnancy was considered a pre-existing condition under some plans. As a result, pregnant women could be denied coverage if they applied for a health insurance plan while pregnant.
Even in cases where insurance was approved, plans often provided little in the way of maternity coverage both before, during, and after the pregnancy. Plans issued after 2014 must contain some maternity coverage, but the type and nature of this coverage are largely left up to the insurance provider.
When it comes to enrolling in health insurance or changing health insurance outside of the Open Enrollment Period, however, pregnancy itself is not considered a qualifying event in every state. Qualifying events are significant life changes that make individuals eligible for a Special Enrollment Period (SEP), which allows them to change insurance coverage outside of the Open Enrollment Period (OEP).
For example, losing job-based insurance coverage or COBRA is considered a qualifying event, as does moving to a different county or zip code. Having a baby or choosing to adopt or foster a child are also considered qualifying events, but pregnancy itself is not. This means that while insurance companies cannot deny coverage based on pregnancy, Special Enrollment Periods to join or change health plans outside of the OEP do not apply until the child is born.
How Will My Pre-existing Condition Be Covered by My Health Insurance?
Health insurance plans issued after 2014 include coverage for pre-existing conditions. While basic health coverage for pre-existing conditions now comes standard, insurers may also offer condition-specific plans that extend coverage for certain conditions. For example, a purpose-built HIV plan may specifically include higher coverage limits for treatments such as new, injectable HIV medications that offer fewer treatment sessions over a longer period.
It’s also worth noting that insurance companies cannot put annual or lifetime caps on pre-existing condition coverage and cannot charge more for these plans. In practice, this means that pre-existing conditions may not lead to increased costs or reduced coverage.
However, depending on the nature of the pre-existing condition, you may still expect to pay more for your healthcare than someone without a pre-existing condition. This could be because your pre-existing condition requires more doctor’s visits, tests, or medication to manage, leading you to seek more extensive health coverage.
Can I Be Denied Health Insurance Due to Pre-existing Conditions?
No. Under the ACA and the Pre-existing Conditions Protection Act of 2021, private insurance companies are prohibited from:
- Limiting or excluding benefits covering preexisting conditions
- Denying enrollment to employers or individual applicants
- Establishing rules for eligibility based on individuals’ health status
- Requiring individuals to pay higher premiums than similarly-situated individuals
Under the ACA, private insurers must also provide coverage for treatments for pre-existing conditions.
There are exceptions to pre-existing conditions coverage for healthcare: grandfathered plans and short-term health insurance.
Grandfathered plans are plans that existed before the ACA came into force. If you have one of these policies, there might still be clauses around pre-existing conditions in it. However, when you purchase a new plan from the same provider or another company, these exclusions no longer apply.
Short-term health insurance plans are not held to ACA standards, so they are permitted to deny coverage for pre-existing conditions. These plans are designed as stopgaps to provide health coverage if you lost coverage but do not have a qualifying life event to allow you to enroll in a health plan outside of the Open Enrollment Period. They can keep you covered until the next enrollment window.
Could There Be a Waiting Period For Pre-existing Conditions?
Under the ACA, there are no waiting periods — also called exclusion periods — for pre-existing conditions coverage. Prior to the ACA, insurance companies could impose an exclusion period of up to 12 months for pre-existing condition coverage. This meant that if you had a pre-existing condition, you were still paying healthcare premiums but could not access coverage for any services or medications related to your pre-existing conditions during the exclusion period.
Grandfathered plans may still implement exclusion periods for coverage, and employer-sponsored health coverage can enforce waiting periods of up to 90 days before coverage goes into effect. Employer plans cannot, however, deny coverage based on pre-existing medical conditions, even if they are not diagnosed until after the policy is active.