Health Insurance 101: What Is a Pre-Existing Condition?

We’re just a bundle of pre-existing conditions, standing in front of an insurance company, asking them to cover us.

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There’s been a ton of discourse lately about pre-existing conditions. More specifically, about whether insurance companies should be able to refuse coverage for certain medical conditions. The truth is, all conditions deserve health insurance coverage. But some plans have different definitions of what a pre-existing condition is. These rules exist mostly for cost savings.

What is a Pre-Existing Condition?

Pre-existing conditions are chronic health problems (like asthma, diabetes, or cancer) that you had before your healthcare coverage began. Historically, insurers were able to opt out of providing coverage for a member’s pre-existing condition after receiving a claim for its treatment. However, if you developed these illnesses after you signed up for insurance, they would be obligated to cover the required services.

By law (under the Affordable Care Act), insurers can no longer refuse to cover treatment or increase out-of-pocket costs for your pre-existing condition. This is also true for pregnancy: Insurers must cover the costs of childbirth and up to 60 days after. This remains effective even if the pregnancy started before enrolling in the insurance plan. Insurance companies consider maternity and newborn care to be “Essential Health Benefits.”

Certain Dates to Remember

This law about pre-existing conditions went into effect January 1, 2014. However, you might still encounter issues with pre-existing conditions under certain plans. For example, you might encounter higher premiums or difficulty securing coverage when it comes to life insurance or certain grandfathered plans. Grandfathered plans commenced before March 23, 2010, so they are exempt from the current rules on pre-existing conditions.

If you need help determining whether your condition will be covered, or which plan is best for you, you can visit the Health Insurance Marketplace at healthcare.gov. You can also call 1-800-318-2596.