Pre-Existing Conditions

Finding and signing up for the right health insurance plan is a confusing process. In addition to comparing benefits and prices, there’s also the guesswork of figuring out what ‘pre-existing conditions' you may have that insurers will use to deny you coverage, charge you more than your neighbor, or eliminate specific benefits you need. Before long, the process goes from complicated and confusing to dizzying and even frightening.

Pre-existing conditions are health problems that individuals already had when they purchased coverage. In the majority of states, insurers do not have to offer you a policy at all if you have a pre-existing condition. If they do, they can price your premium much higher than premiums for healthy people, and they can exclude coverage for the very health problems you sought coverage for. Furthermore, insurers may treat benign conditions—or even something as unavoidable and insignificant as below-average height—as a pre-existing condition. Very few restrictions exist in most states’ laws to curtail these discriminatory practices.

The new law will help Americans with pre-existing conditions starting this year in the following ways:

• Individuals with pre-existing conditions who have been uninsured for at least six months can buy coverage under new “Pre-Existing Condition Insurance Plans.” These plans are available for the same price that healthy people would pay, and they don’t have any exclusions or waiting periods for pre-existing condition coverage.
• Insurers will be prohibited from refusing to cover children with pre-existing conditions. They will also be forbidden from imposing pre-existing condition exclusions for kids.
• Insurers will be prohibited from putting a dollar cap on how much they’re willing to pay for an enrollee’s medical care over the course of their lifetime. This will protect people with health conditions from “running out” of coverage.
• Insurers will be prohibited from rescinding (retroactively canceling) insurance policies due to a person forgetting to mention a past medical treatment or condition. This abusive practice has left people uninsured when they needed coverage the most, even though they followed the rules and paid their premiums on time.

And starting in 2014…

• Insurers will be prohibited from refusing to sell coverage to individuals at any age because of their pre-existing conditions, stopping insurers from cherry-picking the healthiest among us and leaving those with pre-existing conditions out in the cold. Now, only five states require insurers to sell all plans to all people.
• Insurers will be prohibited from excluding coverage for people’s most important health problems, regardless of their age. Now, in 38 states, insurers can sell policies that permanently exclude coverage for people’s pre-existing conditions.
• Insurers will be prohibited from charging higher prices to people with pre-existing conditions than to healthier people.
• Insurers will be prohibited from setting annual dollar caps on how much they will pay in claims for each enrollee over the course of a year. (Before 2014, insurers will only be able to apply restricted annual limits— for example, in 2013, they cannot be any less than $2 million.)