How Pre-Existing Conditions Affect Your Health Insurance Coverage

Are you one of the millions of Americans living with a pre-existing condition? Here's how it may affect your health coverage.

FirstQuote Health Staff
Published on
May 1, 2020
Last Updated on
November 27, 2023
How Pre-Existing Conditions Affect Your Health Insurance Coverage

Living with a pre-existing condition or chronic illness is an issue that faces many of us today. With the advancement of medical technology in recent decades, too many people take their health for granted, but not everyone can afford that luxury. Putting pain, medication, and frequent trips to the doctor aside, pre-existing conditions actually take a heavy toll on your pocketbook, including your health insurance costs. Here’s everything you need to know.

What Is A Pre-Existing Condition?

In the US, a pre-existing condition refers to any medical or health issue an individual has before their health benefits kick in. Historically, health insurance providers would deny membership to any applicant with a pre-existing condition, as they are more expensive to cover. However, that changed in recent years, which we will touch a bit further down.

There’s actually another definition for pre-existing conditions that health insurance companies use. A pre-existing may be any condition an individual has already received care or treatment for prior to becoming a member. While it may sound similar, the slight difference can make a world of a difference.

How Many People Are Living With Them

The number of Americans living with a chronic illness or pre-existing condition is quite astonishing. According to the Centers for Medicare & Medicaid Services (CMS), anywhere between 50 to 129 million US citizens under the age of 65 years old are living with some kind of medical condition.

With so many Americans requiring medical treatment on a regular basis, one can understand why the battle over healthcare is constantly in the headlines. This is not a fringe group of individuals, it’s anywhere between 19% to 50% of the population.

Examples Of Pre-Existing Conditions

When it comes to what’s considered a medical condition by your insurance provider, you, like most people, may be completely blindsided. You would probably expect major medical conditions to fall under the category of pre-existing, but below is a list of some of the most common medical conditions and illnesses. Some of these may shock you:

  • Alcohol abuse/drug abuse with recent treatment
  • Alzheimer’s/dementia
  • Arthritis, Fibromyalgia, and Inflammatory Joint Disease
  • Cancer within some period of time (e.g. 10 years)
  • Cerebral palsy
  • Chronic obstructive pulmonary disease/emphysema
  • Congestive heart failure
  • Coronary artery/heart disease, bypass surgery
  • Crohn’s disease/ulcerative colitis
  • Diabetes mellitus
  • Emphysema
  • Epilepsy
  • Future Surgery or Hospitalization
  • Heart Disease
  • Hemophilia
  • Hepatitis C
  • Kidney disease, renal failure
  • Lupus
  • Mental disorders
  • Multiple sclerosis
  • Muscular dystrophy
  • Obesity
  • Organ transplant
  • Paralysis
  • Paraplegia
  • Parkinson’s disease
  • Pending surgery or hospitalization
  • Pneumocystis pneumonia (PCP)
  • Pregnancy or expectant parent
  • Rheumatoid arthritis, fibromyalgia, and other inflammatory joint diseases
  • Severe obesity
  • Sleep apnea
  • Stroke
  • Transsexualism

How Pre-Existing Conditions Are Determined

Currently, pre-existing conditions are still determined by health insurance companies. Prior to the passing of the Affordable Care Act, more commonly known as Obamacare, insurance providers required applicants to disclose the entirety of their medical history on their applications. If an applicant were to include any medical condition that may require treatment, it will be labeled as a pre-existing condition.

Historically, it wasn’t just what you wrote down on your application that could bar you from coverage. During the underwriting process, it was common practice for insurers to do their due diligence, and gather your medical records. So, even if you didn’t knowingly or unknowingly disclose medical conditions or illnesses, your doctor or healthcare provider may have put something in your file you weren’t aware of. Health insurance companies may have considered anything in your medical history a pre-existing condition.

Will You Have A Waiting Period?

If you aren’t familiar with what a waiting period is, it refers to the length of time between enrolling in health policy and when your benefits kick in. Waiting periods were established as a protective measured from patients enrolling in coverage to get a medical condition or surgery covered without having to remain covered.

Waiting periods still exist under the Affordable Care Act, but they have been limited to about 90 days. Whether or not you will have to wait for your benefits to go into effect in will largely depend on the insurance provider and plan you go with. Make sure to read your policy summary over with your agent or representative to get all the answers to your questions.

The Current Law Says You Can’t Be Denied Coverage

Regardless of what you’ve read in the headlines over the last couple of years, Obamacare is still the law of the land when it comes to health insurance. That means, if you apply for coverage through your state or federal marketplace, you will not be denied coverage due to pre-existing conditions. However, if you apply for coverage in the private sector, you can still be denied coverage based on your medical history.

While the Affordable Care Act does have its flaws, the general consensus seems to be in agreement that pre-existing conditions shouldn’t hinder one’s ability to find affordable health coverage.

What’s even better for those living with a pre-existing condition is additional legislation that prohibits insurers to charge higher premiums based on medical history. Meaning, if you have or apply for health coverage knowing full well you have a chronic condition, your premium will be the same as someone who has a clean bill of health. However, there is an exception to that rule, grandfathered plans.

Exceptions To The Rule: Grandfathered Plans

Grandfathered health plans are policies purchased before the passing of the Affordable Care Act, more specifically, policies purchased on or before March 23, 2010. Even though all new plans purchased are required to cover pre-existing conditions, grandfathered plans are exempt. If you are enrolled in a grandfathered plan, your monthly premiums may see a slight or significant increase if you are diagnosed with any number of medical conditions.

There are still some standards your grandfathered health plan is still required to meet though. For example, these plans can’t apply lifetime dollar limits on your health benefits, be canceled due to an honest mistake on your application, and must still cover your children until they turn 26 years old. If you’d like to switch off your grandfathered plan, you can do so during the next Open Enrollment Period, or compare options with FirstQuote Health today by entering your zip code.

How Pre-Existing Conditions Affect Your Medical Costs

Under the current law, pre-existing conditions have little bearing on your healthcare costs. In fact, as we have previously mentioned, it’s actually against the current law for health insurance companies to charge you more for health coverage due to your pre-existing conditions. However, your medical history will play a role in increased out-of-pocket spending. Let us explain.

Your healthcare spending is a sum total of a few different costs, but most people only focus on their premium, or sticker price. Your premium is a fixed cost you pay each month or billing period in order to stay covered and retain your benefits. However, there are other costs you need to be aware of, especially if you have a pre-existing condition.

For starters, your health benefits won’t actually kick in until you meet your deductible, which typically costs a few thousand dollars. After you meet your deductible, you’ll still have to worry about copays and coinsurance. For people with a clean bill of health, out-of-pocket expenses are relatively cheap. However, if you find yourself making frequent trips to the doctor’s office, your out-of-pocket costs can add up pretty quickly. Make sure to enroll in a plan that accounts for your medical needs.

Lastly, if you require prescriptions or medication, there’s a chance your plan will only cover a portion of your costs. So, while your premium won’t be affected by your pre-existing condition, your wallet may feel the pain due to out-of-pocket expenses.

Finding Complete Coverage With FirstQuote Health

Since the passing of the Affordable Care Act, living with a pre-existing condition is no longer an issue when it comes to finding complete health coverage. However, finding the right coverage to make sure your out-of-pocket expenses don’t get out of control is still a struggle for many.

FirstQuote Health specializes in helping individuals and families find health coverage that meets all their needs, both medically and financially. By working with some of the most reputable companies, we are able to help match you with your perfect plan. To get started, simply enter your zip code, answer a handful of questions, and compare your options side by side in just minutes.

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