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About one in four U.S. adults under 65 have a preexisting condition, such as diabetes or lupus, according to the Kaiser Family Foundation.1 But if you have one, you don’t have to go without health insurance. The Affordable Care Act (also known as Obamacare) doesn’t allow insurers to deny you coverage if you apply for a policy.
Here’s what you need to know about getting health insurance with preexisting conditions.
What is a Preexisting Condition?
A preexisting condition is an illness or injury you have before your health coverage starts.2 Some common ones include:3
- Asthma
- Diabetes
- Cancer
- Pregnancy
- AIDS/HIV
- Alcohol and drug abuse (recent treatment)
- Kidney disease
- Mental disorders
- Severe obesity
- Lupus
Sometimes, upcoming surgery or hospitalization is considered a preexisting condition since the treatment has been on the schedule for a period of time.
Does Health Insurance Cover Preexisting Conditions?
Before the Affordable Care Act (ACA), insurance companies could deny your health insurance application due to your health or health history. That’s different today. An insurance plan can’t reject you or charge you more based on a preexisting condition and they can’t be the sole basis for raising rates on your insurance policy.4
Any Health Insurance Marketplace plan must cover preexisting conditions. This applies to non-marketplace, or non-exchange, plans as well.
If you have catastrophic coverage, your premium can’t be influenced by your condition. However, coverage for some services won’t be as extensive. Catastrophic plans have different requirements that may not be in line with your treatment.
Exceptions to Getting Health Insurance with Preexisting Conditions
There are some situations when health insurance providers may not cover preexisting conditions.
Grandfathered Plans
Grandfathered plans are health plans that were in place before March 23, 2010. They are allowed to offer the coverage they did before the Affordable Care Act.5 These plans don’t have to cover preexisting conditions or offer free preventive care.
Medigap
Companies offering a Medigap policy, or Medicare Supplement Insurance, cannot deny an application for preexisting conditions if the person applies when first eligible for Medicare. If no guaranteed issue right exists, the insurer can deny the application or charge a higher premium. The insurer can also impose a six-month waiting period before covering the preexisting condition if the person did not have at least 6 months of continuous prior creditable coverage before applying.
Medicare Advantage plans, coverage sponsored by private insurance companies, cannot deny any application because of preexisting conditions.
Other Types of Insurance
Other insurance, like short-term medical policies and travel insurance, may have waiting periods. While your preexisting condition may eventually be covered, the wait could last longer than the policy. Always double-check your policy benefits before signing.
This is especially important with short-term plans, which can last up to 364 days and renew for up to three years. Short-term plans are exempt from covering preexisting conditions.
What About Healthshare Programs?
Healthshare programs have grown steadily since the passage of the ACA. They are often religious-based cost-sharing programs that offer a way to cover healthcare costs.6 However, these programs aren’t actually insurance and they don’t have to cover preexisting conditions.
How to Find Health Insurance Coverage for Preexisting Conditions
It’s fairly straightforward to find health insurance for preexisting conditions.
The ACA marketplace in your state also offers access to insurance policies that cover preexisting conditions. For those old enough to qualify for Medicare, preexisting conditions are part of that coverage, too.
Health Insurance Tips When You Have a Preexisting Condition
- Shop around: Compare plans from different insurers. HealthCare.com can help you find different options.
- Compare benefits: Even with employer-sponsored health insurance, policies may differ. Compare the benefits to ensure you have what you need for your preexisting condition.
- Prescriptions: While prescriptions may be covered, some plans have higher out-of-pocket requirements or higher copays for certain drugs. Review coverage for prescriptions you need to manage your preexisting condition. Understand and prepare for the costs.
- Consider prescription discount plans: In some cases, it may make sense to look into drug discount plans that can help you save on required medications.
- Review in-network care providers: When managing a preexisting condition, you may need to see doctors and specialists more often. Check to see that they are in-network to avoid out-of-network costs.
