Can you still get insurance if you have a pre-existing condition?
Firstly, a pre-existing condition means something that you already have when you apply for health insurance. This means that if you already have a disease or illness, say cancer, it would typically be included in your medical history and deemed pre-existing. By the same token, if you are newly diagnosed with cancer, at the point of applying for insurance coverage there is typically no pre-existing condition involved per se.
It’s possible to get insurance even after a pre-existing condition. But it depends on what type of plan or product coverage your current or potential new provider or insurer offers.
How do pre-existing conditions work in insurance?
The Affordable Care Act (ACA) made changes to the previous system. It required health insurers to offer coverage to people with pre-existing conditions, but the actual rules vary by state. There are several factors that determine how insurers deal with pre-existing conditions:
- Is the person applying for health insurance at their ‘first opportunity’ in the marketplace?
- Did they have a prior plan terminated for nonpayment of premiums?
- Did they apply for retroactive coverage?
Now, what does this all mean in practice?
If you are buying health insurance from an individual or group plan, your potential new provider will ask about any pre-existing conditions and your current provider will send them a list if applicable. If you are switching from Medicare to an individual plan, the process is different and you may be able to keep your current coverage.
In addition, if the insurers agree that you have a pre-existing condition, they will typically deny your claim; or switch you to a plan with a higher premium.
However, it’s possible to get insurance if you have cancer or another condition as long as:
- You signed up and paid premiums every month while keeping your original plan in force. If you have an employer’s group health insurance policy and leave employment, the insurer can ask for payment of the claims incurred on or before that date. This is why it’s important to get health insurance while still employed instead of waiting until you leave work.
- You are signing up at your first opportunity in the individual marketplace or with a new employer. If you sign up late due to a lapse in coverage, they may deny coverage or force you to pay extra.
- You applied for retroactive coverage and had policies terminated in the past. The ACA prevents insurers from denying claims that occurred while someone was insured. But they can choose not to offer coverage that started after an individual moved between plans; or waited until the next year’s open enrollment period instead of a normal renewal date.
It’s also reported that some people have been denied care due to pre-existing conditions, although this is less common than previously after the Affordable Care Act was introduced and implemented across most states. Since the law was passed, there have been reports of several cases where people were denied or charged higher premiums for pre-existing conditions.
You can watch this video for additional information about what Affordable Care Act:
While there is no standard set of rules across all states, the ACA introduced a number of changes. Some say that most plans can’t charge more than 50 percent for people who are deemed to have pre-existing conditions. This only applies to essential health benefits, which are 10 mandatory benefits outlined by the ACA. But it’s important for consumers to look at their policies. And it’s to understand any potential exclusions due to the pre-existing condition rule. There could be additional charges or higher premiums. But this is typically capped at 50 percent above what people without conditions pay.
Insurers can also refuse coverage if you had a plan terminated for nonpayment of premiums. It’s such as an individual or small group health insurance policy, not paid in full due to missed payments. If you are eligible for premium tax credits based on your income, this will also be used to determine what your health plan premium should be.
In some states, you may be able to get a waiver saying that you cannot be denied due to a pre-existing condition. In other words, the insurer can’t charge you more. But they may still ask for documentation and payment of the claims in full; or want proof that you are covered through insurance elsewhere.
Some state laws make it easier to obtain coverage. It’s in the condition that your provider thinks you have a pre-existing condition, but this doesn’t apply across all states. This can help people who have an illness without being denied health insurance entirely, although insurers may still require inspections of medical records..
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