What are the rules for pre-existing condition exclusions?

According to the Department of Health and Human Services, as many as 19 to 50 percent of Americans under age 65 have some type of pre-existing condition - a known medical condition that you have before you apply for insurance.
You or someone you love may have one of the most common - heart disease, which according to the American Heart Association affects one in every three adults. But even if you have something relatively less serious, such as an overbite or hay fever, it can cost you higher premiums and in some cases loss of coverage.

As of summer 2011, the Affordable Care Act outlined the following concerning pre-existing conditions, with some changes occurring in 2010 and others being phased in later in 2014. Under the Act, your insurance company will no longer be allowed to limit or deny coverage based on your pre-existing conditions and your premiums may not be higher than those of other beneficiaries of the same age, sex, and location. In the meantime, the federal government will offer a new program to provide an affordable option for high-risk individuals with pre-existing conditions.

The Act offers the following specific protections from discrimination based on pre-existing conditions:
  • Outlaws denial or limiting of coverage for pre-existing conditions, beginning in 2014;
  • Makes pre-existing condition insurance plans available until then through a program called the Pre-Existing Condition Insurance Plan (PCIP); 
  • Eliminates pre-existing condition denials for children under age 19 as of 2010 (This new rule applies to all employer-sponsored health plans and individual health insurance policies issued after March 23, 2010, and for plan or policy years that began on or after September 23, 2010.); 
  • Prohibits insurance companies from charging patients more because of pre-existing conditions.
Beginning in 2014, if you choose to purchase insurance from your state exchange (a marketplace where you can compare private insurance company policies), pre-existing conditions will no longer prevent you from getting the coverage you want and you will be eligible for the same coverage as everyone else at a competitive price.

Continue Learning about Healthcare Reform

Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.