Pre-existing condition - Glossary (2024)

FAQs

Can I be denied health insurance because of a pre-existing condition? ›

Under the Affordable Care Act, health insurance companies can't refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts. They also can't charge women more than men.

Insurers generally define what constitutes a pre-existing condition. Some are obvious, like currently having heart disease or cancer. Others are less so – such has having asthma or high blood pressure.

The ACA bars use of pre-existing conditions

The ACA complements the Genetic Information Nondiscrimination Act (GINA) which prohibits discrimination by most health insurance plans and employers based on genetic information such as an inherited genetic mutation associated with an increased risk of cancer.

If your health plan is fully compliant with the ACA and obtained in either the individual/family market or the employer-sponsored market, you no longer need to worry about pre-existing condition exclusion periods.

People with pre-existing conditions can still qualify for various life insurance policies. However, they may pay more in premiums because personal health history is a key factor that insurers use to calculate rates.

In the health insurance world, a pre-existing condition is any injury, sickness or condition that exists before the date an insurance policy takes effect. Examples include asthma, diabetes, anxiety, depression, high blood pressure, high cholesterol and so on.

You may have gone for tests, scans or other investigations before you had health insurance and only received a diagnosis later. It applies to any medical condition that you saw your doctor about the five years before the start date on your health insurance.

A pre-existing condition exclusion can not be longer than 12 months from your enrollment date (18 months for a late enrollee). A pre-existing condition exclusion that is applied to you must be reduced by the prior creditable coverage you have that was not interrupted by a significant break in coverage.

Yes. When you sign up for Original Medicare, any preexisting condition will be covered immediately. However, you'll still be responsible for all out-of-pocket expenses like deductibles, copayments and coinsurance.

Declinable Pre-existing Conditions

Insurers maintained lists of health conditions for which applicants would routinely be denied coverage. Declinable conditions included AIDS/HIV, congestive heart failure, diabetes, epilepsy, severe obesity, pregnancy, and severe mental disorders.

What is the look back period for pre-existing conditions? ›

Travel insurance companies impose a “look-back period,” which is a specific time frame when a pre-existing condition is considered stable, usually between 60 and 180 days.

Under Federal law, a "pre-existing condition" is any condition (either physical or mental) for which medical advice, diagnoses, care, or treatment was recommended or received within a six month period immediately preceding enrollment in a health plan.

You cannot be denied coverage based on preexisting conditions. No. You must answer a series of medical questions to apply for coverage.

Original Medicare ( Part A and Part B ) has helped cover preexisting conditions since it began in 1965. And thanks to the Affordable Care Act signed in 2014, there are no additional costs for Original Medicare coverage if you have preexisting conditions.

How are pre-existing conditions determined? A pre-existing condition is a health issue that required diagnosis or treatment prior to an applicants' enrollment in a health plan.

Before 2014, some insurance policies would not cover expenses due to pre-existing conditions. These exclusions by the insurance industry were meant to cope with adverse selection by potential customers. Such exclusions have been prohibited since January 1, 2014, by the Patient Protection and Affordable Care Act.