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Health Insurance Coverage
Insurance companies can’t deny you coverage based on pre-existing conditions.
Updated April 28, 2021|3 min read
Table of Contents
Pre-existing conditions are medical conditions and health problems that you had before the start date of your health insurance coverage. Examples of pre-existing conditions include cancer, asthma, diabetes, and even pregnancy.
Under the Affordable Care Act (Obamacare), health insurance companies cannot refuse to cover you because of any pre-existing conditions nor can they charge you more money for coverage or subject you to a waiting period. These Obamacare rules affect plans that began on or after January 1, 2014.
A pre-existing condition is any health condition or injury you have before enrolling in a health insurance plan
All pre-existing conditions are covered under the Affordable Care Act (Obamacare)
Insurers cannot deny health coverage for people for pre-existing conditions
Insurers cannot charge higher costs or subject people with pre-existing conditions to a waiting period
Prior to Obamacare, insurance companies could reject people for any number of pre-existing health conditions and people had to instead enroll in a pre-existing condition insurance plan (PCIP) — a health program specifically for individuals who had been rejected on the basis of a medical condition. PCIP coverage ended in 2014 when the Obamacare protections went into effect.
Just about any health condition that you have prior to the start of an insurance policy can qualify as a pre-existing condition. Make sure to check the exact details of a plan since each health insurance company decides what it considers a pre-existing condition. Even a more minor medical condition — like acne, tonsillitis, high blood pressure, or menstrual irregularities — could be deemed a health issue, depending on the provider.
According to the Kaiser Family Foundation, common examples of pre-existing conditions that affected coverage before the ACA are:
Depression and other mental health disorders
Dementia and Alzheimer’s
Heart disease, coronary artery, bypass surgery
Pending surgery or hospitalization
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If you are pregnant before the start of a new health insurance plan, it qualifies as a pre-existing condition regardless of how long you have been pregnant. Every health insurance policy must cover pregnancy and childbirth and the 10 essential health benefits, which include maternity care and newborn care.
Because of the Affordable Care Act, you are guaranteed coverage of pre-existing conditions if you enroll in a health insurance plan that starts on or after January 1, 2014. Insurance companies cannot deny you health coverage based on a pre-existing condition, including pregnancy. It is also illegal for them to charge more money for your plan just because of a pre-existing issue. However, each insurance company does have a lot of leeway to set its own prices and to decide the exact services that it covers, so just because something is covered by your plan doesn’t necessarily mean it will be free or even affordable in all cases.
Note that other types of health plans, like short-term health plans, don’t usually cover pre-existing conditions or only do so at very high prices. Certain health conditions or your medical history may also prevent you from being able to get other types of insurance, such as life insurance or disability insurance.
Health insurance plans that started on or before March 23, 2010 — called grandfathered plans — are not subject to the rules of Obamacare. If you enrolled in a health plan prior to this date, your insurer can choose to cancel your policy or increase your premiums for pre-existing medical conditions. It is also possible for an employer to maintain and enroll new employees in a grandfathered plan under certain circumstances. An employer must notify you that it has a grandfathered plan. If your employer offers a grandfathered plan but you need coverage for a pre-existing condition, you can get a plan through the Obamacare marketplace.