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Finding Insurance Coverage When You Have a Pre-Existing Condition

If you are like 130 million Americans with health issues like asthma, high blood pressure or diabetes, then you are probably considered someone with a pre-existing condition by insurance companies. Technically speaking, a pre-existing condition is any health problem for which you have already received medical advice or treatment, but what actually constitutes a pre-existing condition is largely left up to the insurer.

Just a few years ago, if you had a pre-existing condition, then you would have likely had to pay more to get health insurance.  In many cases, insurers would not even issue you a policy if you had serious health conditions like cancer or organ failure which would be extremely costly to treat. For more than half of all Americans with one or more pre-existing conditions, obtaining health insurance was difficult, if not impossible.

Affordable Care Act

In 2010, Congress passed the Patient Protection and Affordable Care Act, also known as ACA or Obamacare.  This sweeping health care reform law made many changes to the American health care system, but one of the most popular and important was the “Community Rating.” The Community Rating provision prohibited insurers from discriminating against people with pre-existing conditions.

It became illegal for insurers to charge enrollees more if they were sick or deny them coverage based on prior illness.  The ACA also required that all health plans include certain Essential Health Benefits which included:

  • Emergency services
  • Hospitalization
  • Outpatient services
  • Maternity care
  • Mental health and addiction treatment
  • Prescription drugs
  • Rehabilitative services
  • Preventive health
  • Pediatric care
  • Laboratory services

Because all health insurance policies included these Essential Health Benefits, no one with a prior health condition could be sold a policy that would not cover major medical services.

The Community Rating clause of the ACA also affected employer health plans. Prior to ACA, employer health plans could impose a waiting period before coverage began for workers with prior health conditions.  In some circumstances, this waiting period could last up to 12 months, and this applied to people who switched jobs or were uninsured for 63 or more days.

If you are still on a health plan from before passage of the Affordable Care Act, your insurer may still be able to charge you more if you had a pre-existing condition, or deny you coverage for various services related to prior health issues.  Insurers may still consider other factors in issuing a health insurance policy including age, geographical location, family size and tobacco use.

If you are not sure if your current health plan complies with the Community Rating or other provisions of the Affordable Care Act, you may find answers with one of Boost Health Insurance’s many knowledgeable service representatives.

What to Do If Your County Only Has One Insurer

New Health Care Reform Efforts

Although the Affordable Care Act was a boon for many Americans with pre-existing conditions who could finally obtain health coverage at an affordable rate, the new law had many problems.  Among these was the lack of voluntary participation of younger, healthy Americans. Despite the inclusion of the Individual Mandate (which financially penalize Americans without health insurance), there were too few healthy enrollees, leaving only those with pre-existing conditions in the insurance pool.

Because those signing up for health coverage on the ACA-sponsored health insurance exchanges were predominantly the sick who couldn’t get insured before, the costs for insurers were significantly greater than expected.  Without younger, healthier enrollees joining these coverage populations to offset the more expensive enrollees, insurers were paying more than expected.  This, of course, led to higher premiums for most enrollees as well as departures for many insurers from the exchanges.

Healthcare Reform

Diminishing competition and skyrocketing insurance premiums were the primary drivers of the more recent health care reform initiatives in Congress.  New proposals like the American Health Care Act that passed in the U.S. House of Representatives would have stripped the Community Rating from federal law books and allowed insurers to consider pre-existing conditions when issuing policies.

Future of the Community Rating

Fortunately, neither of the proposals put forth by the House of Representatives or the Senate were ratified into law.  At least for the moment, the Affordable Care Act remains the law of the land so it remains illegal for insurers to discriminate against those with pre-existing conditions.

While this is great news for many Americans, it may be a situation that you should take advantage of now while you still have the chance.  There is no guarantee that Congress won’t take up health care reform again at some point, and, if they are more successful in the next round of lawmaking, then the Affordable Care Act could disappear along with its protections for people with pre-existing conditions.

It may be in your best interest to sign up for health insurance while the ACA is still in force because if it is repealed, your policy will likely remain unchanged due to a “grandfathered” clause in future laws. Your grandfathered policy probably won’t allow your insurer to raise rates or deny you coverage due to a pre-existing condition even under a new law without such protections.

There is also some doubt as to whether any new laws would include a rollback in protections for pre-existing conditions because so many sick people have obtained health coverage under Obamacare. In a recent poll by the Cato Institute, almost 63 percent of respondents supported the Community Rating provision.  This high level of support among the American public would make a repeal of that part of the law politically much more difficult.

The recent failure of the Republican-controlled Congress to repeal the Affordable Care Act also highlights the popularity of the new health care entitlement. Following the passage of the House’s American Health Care Act, which would have led to millions of Americans losing their health coverage, the popularity of ACA topped 51 percent, the highest since its passage.  Any future efforts to dismantle the Obamacare insurance system is likely to meet staunch resistance from an American public that is enjoying the many benefits.

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