Health Insurance: Paying for Pre-Existing Conditions

Before the Affordable Care Act (ACA) became law in March 2010, the words pre-existing condition and experimental procedure were often bad news for patients in the United States. In many cases, health insurance providers were not required to cover associated costs or would even deny coverage to individuals with pre-existing conditions.

However, under the ACA, anyone with a pre-existing condition can get health insurance, and companies are not allowed to charge you more for pre-existing conditions, either.

The only exception is for those individuals who have a "grandfathered individual health insurance plan." These plans are not required to cover pre-existing conditions because they are plans that were purchased before the ACA law.

Key Takeaways

  • Experimental procedures may be covered by health insurance providers, although there are exceptions.
  • A pre-existing condition refers to a physical or mental condition caused by a medical illness or injury that existed before a person signed up with a health insurance provider. 
  • Objective standards and prudent persons are two definitions insurance companies use to define pre-existing conditions.
  • As of 2014, under U.S. law, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition”.
  • Insurers are not allowed to charge women more than men when they sign-up for insurance.

Defining Pre-Existing Condition

A pre-existing condition is a medical illness, injury, or other condition that a patient had before signing up with a health insurance provider. Most insurance companies use one of two definitions to identify such conditions.

Under the "objective standard" definition, a pre-existing condition is anything the patient has already received medical advice or treatment before enrollment in a new medical insurance plan.

Under the broader "prudent person" definition, a pre-existing condition is anything for which symptoms were present, and a prudent person would have sought treatment. Pre-existing conditions can include serious illnesses, such as cancer. It can also include less serious conditions, such as a broken leg, and in some cases, even prescription drugs can count as a pre-existing condition. Pregnancy is considered a pre-existing condition.

3 Examples of Insurance and Pre-Existing Conditions

Though the definitions are fairly easy to understand when you know which will apply to your circumstances, it may get more complicated after you factor in the additional rules regarding coverage, even though by law all insurers must cover pre-existing conditions.

Navigating through the bureaucracy begins with understanding the Health Insurance Portability And Accountability Act (HIPAA), which provides limited protection for consumers enrolled in group health insurance plans concerning healthcare coverage.

Prior to the ACA, pregnancy was considered a pre-existing condition, and many medical plans excluded maternity coverage if a woman purchased her own healthcare plan.

Changing Jobs

The first involves changing jobs. If you were covered under your prior employer's healthcare plan and take a job with a new employer, your new employer's health insurance plan can impose a six-month "look back" period.

In the past, during that time, you must have had creditable coverage with no breaks in excess of 63 days to get immediate treatment for a pre-existing condition but thanks to the ACA, it is no longer the case. Creditable coverage includes group healthcare plans, private health insurance, and COBRA coverage; it can also include Medicare or Medicaid.

Purchasing Private Healthcare Insurance

In the second scenario, if you had employer-sponsored healthcare coverage and wanted or needed to purchase private healthcare insurance (because your COBRA ran out, say), HIPAA and the ACA guarantees that the new insurer will cover pre-existing conditions provided you have had continuous healthcare coverage with no breaks longer than 63 days during the past 18 months.

Switching Insurance Providers

Again, in the past, if you had an insurance plan that you purchased on your own that was not affiliated with your employer, you would have had trouble finding coverage for a pre-existing treatment.

Experimental Procedures and Insurance Coverage

Though getting health insurance coverage when you have a pre-existing condition is no longer a challenge, getting an insurance company to pay for an experimental treatment can sometimes be impossible. Experimental procedures are categorized by a wide variety of definitions.

For example, "not generally accepted by the medical community" is a phrase commonly heard in relation to experimental procedures. These investigative treatments are often part of the effort to develop treatments and cures for serious illnesses, such as cancer. But they are often also quite expensive, so insurers have a financial incentive to refuse coverage. Various stem-cell treatments are examples of the type of procedure that can fall into this category, although some insurance will cover them.

To find out which procedures your healthcare provider categorizes as experimental, read your policy information. If you cannot find the details in the materials that you have, contact your provider and ask for a written overview of coverage policies.

If you seek treatment for a procedure categorized as experimental and is therefore denied by your insurance provider, you can appeal the decision. If you lose the appeal, you can take the case to court, although the legal system often grinds forward very slowly, which could be detrimental to someone who's seriously ill.

The Bottom Line

Thankfully, the days of insurers rejecting buyers with pre-existing conditions are over. However, if you have an insurance policy that was purchased on or before March 23, 2021, it may not include the protections and rights granted by the ACA, and you should ask before you purchase a "grandfathered" type of plan, which are still sometimes sold to individuals.

If you lose your job, sign up for COBRA to continue your benefits, and when your COBRA coverage ends, plan on purchasing insurance through ACA's marketplace exchange, and you will not have to worry about any pre-existing conditions keeping you from healthcare plans.

Article Sources
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  1. "Affordable Care Act (ACA)."

  2. U.S. Department of Health and Human Services. "Can I Get Coverage if I Have a Pre-existing Condition?"

  3. "How Obamacare changed maternity coverage."

  4. Centers for Medicare & Medicaid Services. "The Health Insurance Portability and Accountability Act (HIPAA) of 1996 Helpful Tips," Page 4.

  5. "Medical Necessity Definitions."

  6. The National Stem Cell Foundation. "FAQS."

  7. U.S. Department of Health and Human Services. "Can I Get Coverage if I Have a Pre-existing Condition?"