Does marketplace insurance cover pre existing conditions

The Affordable Care Act – also known as the ACA or Obamacare – provides health care coverage protections to people with preexisting conditions.

Learn how this law affects you below.

If you’re an employer, learn what you need to know about the ACA.

What is a preexisting condition?

A preexisting condition is a health condition you had before your health care coverage started.

What qualifies as a preexisting condition?

Preexisting conditions tend to be chronic, long-term illnesses. Conditions like asthma, COPD, sleep apnea, diabetes and cancer could all be preexisting conditions.

What does the Affordable Care Act (ACA) say about it?

Before the ACA, health insurance providers could deny people coverage or charge significantly more for a long-term illness. Now, all Marketplace plans through the ACA are required to cover treatment for preexisting medical conditions.

Under the ACA, health insurance companies also can’t charge women more than men for the same coverage.

Can insurance be denied for preexisting conditions?

Insurance plans can’t deny you coverage for a condition you had before your coverage.

Pregnancy care and childbirth are also covered starting on the day your plan begins. If you’re pregnant and applying for coverage, an insurance company can’t reject you or charge you more based on your pregnancy.

Can insurers charge more for preexisting conditions?

Insurers can’t charge you more or refuse to pay for essential health benefits for any preexisting condition. And after you’ve enrolled, your health insurance company can’t raise your rates based only on your health.

What are some exceptions to preexisting conditions coverage?

Grandfathered individual health insurance plans are the only exception to the ACA’s preexisting coverage rule. Plans purchased on or before March 30, 2010, aren’t required to cover preexisting conditions or preventive care.

If you have a grandfathered plan and want coverage for preexisting conditions, you have two options:

• You can switch to a Marketplace plan during open enrollment.
• You can buy a Marketplace plan outside of open enrollment when your grandfathered plan ends. This qualifies you for a special enrollment period.

If you’re looking for individual or group health insurance, call us at (888) 501-4560 to connect with an agent, request a quote or email us.

Current Sanford Health Plan members can access their summary of benefits and coverage through our secure member portal or by contacting customer service using the number listed on the back of their member ID card.

If you’re ready to compare plans for yourself, find our buyer’s checklist here. You can also call us at (888) 501-4560 to talk to one of our experts and start setting up your plan. Related Content How to find health insurance after losing coverage The benefits of working with an agent

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Many things affect your health insurance premium, and a pre-existing condition can significantly affect it in a negative manner. 

Unfortunately, you can expect to pay a dramatically higher premium if you have a pre-existing condition. The reason that your premiums will be higher is that it is expected that your chronic condition could become very costly and even require expensive procedures or surgery at some point. 

What is a pre-existing condition?

Approximately 25% of adults under age 65 have pre-existing conditions, according to a 2019 study published by the Kaiser Family Foundation. As the Patient Advocate Foundation notes, a pre-existing condition is a health condition, illness, or injury that you know about—perhaps even have received or have scheduled treatment—before applying for health insurance coverage.

Some examples of pre-existing conditions include:

• Pregnancy
• Epilepsy
• Asthma
• Sleep apnea
• Cancer
• Diabetes

Pre-existing conditions, of course, are not limited to these few examples, and you should make sure to read the specifics of any plan you’re considering to make sure that your plan covers any medical conditions or health problems you have.

Insurance companies used to sometimes charge more or refuse people with pre-existing conditions. This is because more health problems will result in a high-risk pool of members—which means the insurance company was dishing out more money for people who actually used their individual health insurance to its fullest extent.

Pregnancy as a pre-existing condition

In some cases, individuals may be confused about whether pregnancy is a pre-existing condition. Pregnancy is a pre-existing condition, but it’s not treated in the same way as other illnesses. Your insurance premium will not be increased, nor will you be denied maternity coverage if you become pregnant prior to seeking insurance. 

Can I get health insurance with a pre-existing condition?

You can get health insurance if you or a family member has a pre-existing condition. However, prior to the implementation of the Affordable Care Act (ACA), it was nearly impossible for individuals to obtain health insurance with pre-existing conditions. This has not always been the case. 

Prior to the 2010 passage of the Affordable Care Act (also known as “ACA” and Obamacare), insurance companies could refuse coverage for the pre-existing condition(s), charge significantly higher premiums to insure people with pre-existing conditions, or reject the applications for health insurance from people with pre-existing conditions. This was because insurance companies were paying astronomical amounts for healthcare for individuals with pre-existing conditions, and since they weren’t required to accept all applicants, they began determining what pre-existing conditions are not covered.  Pre-existing conditions posed sometimes insurmountable barriers to changing jobs, changing health insurance, and finding affordable care. But that is largely a problem of the past.

Not only was the Affordable Care Act passed in order to give people access to affordable healthcare coverage, but it was also passed to protect people with pre-existing conditions. These individuals can no longer be denied coverage, and if you’re wondering whether an insurer can charge more for pre-existing conditions, then the answer is “no,” although other conditions (e.g., age, where you live, how many people in your family require coverage, which specific plan you choose), can affect your rates. 

Will a pre-existing condition result in a higher premium?

Under current law, insurance companies cannot charge higher premiums or refuse health insurance coverage due to pre-existing conditions. If you’re buying an ACA-compliant individual health insurance plan, you won’t have to worry that health insurance is out of reach because of pre-existing conditions you or a family member may have. You still need to compare health insurance plans’ costs and coverages, however, to make sure you are choosing health plan coverage that best meets the needs of you and your family.

A licensed eHealth insurance agent is available to help you understand your health insurance options and identify plans that are likely to result in the affordable care you and your family need.

Can I get Medicaid and CHIP coverage with pre-existing conditions?

The ACA has also made it impossible for Medicaid and CHIP programs to deny coverage to individuals with pre-existing conditions. 

As a result, as long as you’re able to qualify for these programs, you can receive coverage for your chronic conditions from the very first day. Plans purchased through the Marketplace offer the best medical insurance for pre-existing conditions, and if your income is low enough, Medicaid and CHIP do, as well. 

What actually affects my health care costs?

When considering purchasing the best medical insurance for pre-existing conditions, there are other factors that can affect your health care costs besides pre-existing conditions. 

For example, this can include your family size, whether or not you use tobacco, and which insurance plan you end up purchasing. Also, not all health insurance plans offer coverage for pre-existing conditions. If you fail to choose a plan through the Marketplace and you have a pre-existing condition, then your healthcare could end up being nearly impossible to afford. Another option to 

Is there a waiting period for health insurance coverage to be applicable for pre-existing conditions?

Depending on the specific medical plan that you end up purchasing, there could be a waiting period before pre-existing conditions are covered. This period could be anywhere from 12-18 months, meaning that if you receive treatment for your condition prior to this period having passed, then you must pay for costs out-of-pocket. To understand the specifics of your plan, contact your health insurance provider.

Watch out for these types of health insurance plans if you have pre-existing conditions

If you or a family member has a pre-existing condition, you should be aware of the two main exceptions in which health insurers may not cover pre-existing conditions.

1. Short-term medical policies. Short-term medical policies are exempt from the law requiring insurance coverage for pre-existing conditions. Even short-term medical insurers that accept your application may impose a wait period before they will cover treatment related to a pre-existing condition. A short-term medical policy may be in effect from 90 to 364 days and may renew up to three (3) years. Given its relatively short duration, a short-term policy might not help you pay for treatment of pre-existing conditions even if the insurer accepted your application.
2. Grandfathered group health plans. If you can obtain coverage for yourself or a family member with a pre-existing condition under an employer’s or union’s group health coverage, be sure to check first with the plan administrator to see if the plan is “grandfathered.” Grandfathered plans are health plans that were in place before March 23, 2010. By law, these health plans can offer the same benefits today they offered before the Affordable Care Act. They may restrict or exclude coverage for pre-existing conditions.

How can I get health insurance with a pre-existing condition?

If you have a pre-existing condition, then it’s important that you take your time when switching insurance with a pre-existing condition in order to find the best medical insurance. If you fail to find the best health insurance plan for your pre-existing condition, then you could end up being denied coverage for your illness and have to pay substantial amounts out of pocket. 

It’s easy to find health insurance with a pre-existing condition. ACA-compliant health insurance is available from your state’s marketplace and off the marketplace. Let eHealth help you find the plan that is right for you. You can start your search now by checking out all the individual and family health insurance plans available in your area. Simply answer a few questions about your health insurance needs and select Find ACA Plans. The eHealth plan search tool will identify the plans available where you live and permit you to compare costs and benefits. Our health insurance brokers and agents are available to assist you as well. At eHealth, our goal is to help you find effective health coverage at an affordable price—regardless of your current health condition.

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