What Is a Pre-Existing Medical Condition? Everything You Need to Know


Are you without health care insurance coverage? If so, you’re not alone. Over two million poor Americans have no insurance. This is because several states have opted to not expand their Medicaid program.

Many people have trouble getting insurance in non-ACA states due to a pre-existing medical condition. If you are not familiar with these issues, continue reading this article. All Americans must know about the problems related to access to medical care.

What Is a Pre-existing Medical Condition?

Insurance companies developed the concept of pre-existing medical conditions. Before 2014, most health insurance companies screened for medical problems and limited coverage.

For example, they might refuse to provide insurance policies to people with cancer. You often had to wait before getting coverage for expenses related to prior conditions.

Affordable Care Act Coverage and Pre-existing Conditions

The Affordable Care Act (ACA) or Obamacare was passed in 2014. This instituted coverage standards to stop insurer discrimination. The following are examples of conditions that affected insurance coverage before the ACA.

  • Asthma
  • Cancer
  • Cerebral palsy
  • Depression or other mental health conditions
  • Dementia and Alzheimer’s Disease
  • Diabetes
  • Epilepsy
  • Gender dysphoria
  • Heart diseases including coronary artery disease and coronary artery bypass surgery
  • Hemophilia
  • Hepatitis C
  • Lupus
  • Obesity
  • Paraplegia
  • Pregnancy
  • Prescheduled surgeries or hospitalizations
  • Sleep apnea
  • Stroke

With ACA, insurance companies can’t refuse coverage or raise premiums for pre-existing conditions. There is an exception for “grandfathered individual health insurance policies”.

This describes a personal insurance policy you bought on or before March 23, 2010. There can’t be any specific changes to the policy. This includes decreasing benefits or increasing costs.

Individuals Caught in the Insurance Gap

The ACA expanded Medicaid healthcare coverage for millions of Americans. Almost all individuals at or below the 138% poverty level are now eligible for Medicaid. In 2020, the 138% poverty level is a $17,609 yearly income for an individual.

The ACA’s plan was for Medicaid to cover all low-income Americans. There’s no financial plan for people below poverty. It also doesn’t offer other medical coverage options.

This has created a group of adults that are now caught in a gap without insurance coverage. These people’s income is too high to receive Medicaid. Yet, they are below the lower limit for Marketplace premium tax credits.

Most of these individuals include adults who don’t have dependent children.

What Is Short Term Insurance?

Short term insurance provides medical coverage for up to 12 months. This can help if you’re between jobs or waiting for a government-sponsored health benefit. Individuals may also buy this insurance if they miss the ACA enrollment period.

This type of insurance doesn’t cover the ACA’s 10 essential health benefits. Their purpose is to provide protection against unexpected illness or injury. They only cover emergency services.

You may buy a plan for 30 days to 12 months. Their approval process is fast and becomes effective as soon as one day after you’re approved. These programs often cost less than traditional plans.

Pros and Cons of Short-Term Insurance

Short term insurance plans can reject people with certain health conditions. This includes people with pre-existing medical conditions. They are not held to ACA rules.

Their premiums are lower because they don’t include people with pre-existing conditions. This offers a benefit for healthy individuals who need coverage for a short time.

It’s important to know that short-term insurance isn’t renewable. You are allowed to enroll in a different short-term policy. Yet, you’re only allowed to do this about twice a year.

This plan isn’t for those planning a pregnancy, mental health care, or have health problems. Instead, check into ACA major medical plans. These plans accept those who have pre-existing medical conditions.

Having medical insurance is less expensive than paying out-of-pocket for healthcare treatment.

Options for Buying an Individual Health Insurance Plan

You can buy health insurance if you have no other point of access. There are open enrollment periods often at the end or very beginning of the year. If you have a “qualifying life event”, you can buy a health plan at a different time.

The following life events allow you a 60-day “special enrollment period”.

  • Marriage
  • Having a baby or adopting a child
  • Placing a child for adoption or foster care
  • Moving to a different location
  • Becoming a U.S. citizen
  • Being released from prison
  • Losing health coverage because of job loss, divorce, COBRA expiration, or aging off your parent’s insurance
  • Loss of eligibility for Medicaid or the Children’s Health Insurance Program (CHIP)

You may qualify for a special enrollment period if you have a marketplace plan or status changes. One example includes an increase or decrease in your income.

Any difference in the household status may allow you to enroll at a different time. The change must alter the eligibility for premium tax credits or cost-sharing reductions.

Becoming a member of an Indian tribe allows you to take part in the special enrollment period. Anyone who qualifies for Medicaid or CHIP may enroll at any time during the year.

Individual health care plans may not reject your application or raise premiums due to a pre-existing condition. These plans provide coverage for:

  • Outpatient care
  • Emergency room care
  • Hospitalizations
  • Surgery
  • Pregnancy and maternity care
  • Treatment for mental health and substance abuse
  • Prescription drugs
  • Services or equipment for recovery or disabilities
  • Lab tests
  • Health screenings
  • Immunizations
  • Contraceptives
  • Pediatric care including dental and vision

Preventative care is free when you see a provider that’s in the healthcare plan’s network.

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About Author

LaDonna Dennis

LaDonna Dennis is the founder and creator of Mom Blog Society. She wears many hats. She is a Homemaker*Blogger*Crafter*Reader*Pinner*Friend*Animal Lover* Former writer of Frost Illustrated and, Cancer...SURVIVOR! LaDonna is happily married to the love of her life, the mother of 3 grown children and "Grams" to 3 grandchildren. She adores animals and has four furbabies: Makia ( a German Shepherd, whose mission in life is to be her attached to her hip) and Hachie, (an OCD Alaskan Malamute, and Akia (An Alaskan Malamute) who is just sweet as can be. And Sassy, a four-month-old German Shepherd who has quickly stolen her heart and become the most precious fur baby of all times. Aside from the humans in her life, LaDonna's fur babies are her world.

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