What Is a Pre-Existing Condition?
A pre-existing condition is any health condition you had before your health coverage started. This includes everything from chronic conditions like diabetes, heart disease, and cancer to conditions like asthma, depression, or even pregnancy.
Examples of Pre-Existing Conditions
- Chronic diseases: Diabetes, heart disease, COPD, kidney disease
- Cancer: Current or history of any type of cancer
- Mental health: Depression, anxiety, bipolar disorder, PTSD
- Autoimmune conditions: Lupus, rheumatoid arthritis, Crohn's disease
- Pregnancy: Historically treated as a pre-existing condition
- HIV/AIDS: Previously used to deny coverage entirely
- Prior surgeries: Heart surgery, joint replacements, organ transplants
Before the ACA (2010), insurers could deny you coverage entirely, charge you dramatically higher premiums, or exclude coverage for your pre-existing condition. The ACA made these practices illegal for most health plans - but some exceptions still exist.
ACA Pre-Existing Condition Protections
The Affordable Care Act includes several key protections that apply to most health insurance plans. Understanding these protections is essential for knowing your rights.
Guaranteed Issue
Health insurers cannot refuse to sell you coverage based on your health status. This means they must offer you a policy even if you have cancer, heart disease, or any other condition. This applies during open enrollment and special enrollment periods.
No Pre-Existing Condition Exclusions
Insurers cannot exclude coverage for your pre-existing condition. If you have diabetes, the plan must cover diabetes treatment. They cannot impose a "waiting period" for coverage of pre-existing conditions.
Community Rating
Insurers can only vary premiums based on a limited set of factors: age (within limits), geographic location, tobacco use, and family size. They cannot charge you more based on your health status or medical history.
What Plans Are Protected?
Individual Marketplace Plans
All plans sold on Healthcare.gov or state marketplaces have full ACA protections.
Fully ProtectedEmployer Group Plans
Group health plans (large and small employer) cannot exclude pre-existing conditions.
Fully ProtectedIndividual Plans (Off-Marketplace)
ACA-compliant individual plans sold outside the marketplace have the same protections.
Fully ProtectedShort-Term Health Plans
Can deny coverage or exclude pre-existing conditions. Not ACA-compliant.
Limited ProtectionHealth Sharing Ministries
Not insurance - can exclude pre-existing conditions and deny claims.
NOT ProtectedGrandfathered Plans
Plans that existed before 3/23/2010 may have some exemptions from ACA rules.
VariesPlans That May Not Protect Pre-Existing Conditions
While the ACA provides strong protections, certain types of coverage are not required to comply with pre-existing condition rules. Be very careful with these products.
Short-Term Health Insurance
Short-term limited duration insurance (STLDI) is explicitly exempt from ACA requirements. These plans can:
- Deny you coverage based on your health history
- Exclude coverage for pre-existing conditions
- Charge you more based on your health status
- Cancel your coverage if you get sick
Short-term plans may seem cheaper, but they provide far less protection. If you have any pre-existing condition or develop one while on a short-term plan, you could face huge out-of-pocket costs or no coverage at all. Only consider these as a true last resort.
Health Sharing Ministries
Health care sharing ministries are religious organizations where members share medical expenses. They are NOT insurance and are NOT regulated as such. They can:
- Exclude pre-existing conditions entirely
- Limit coverage for pre-existing conditions
- Deny "sharing" for any reason
- Impose lifestyle requirements (no tobacco, alcohol, etc.)
Fixed Indemnity Plans
Fixed indemnity plans pay a set amount for specific services (e.g., $100/day for hospitalization) regardless of actual costs. These are supplemental products that don't provide comprehensive coverage and don't have to follow ACA rules.
California limits short-term health plans to a maximum of 3 months (compared to the federal allowance of up to 36 months). The state has also strengthened disclosure requirements so consumers understand these plans don't provide ACA protections.
Historical Context: Life Before the ACA
To understand why pre-existing condition protections matter, it helps to know what the insurance market looked like before the ACA.
What If You're Denied Coverage for a Pre-Existing Condition?
If you believe you've been illegally denied coverage or charged more because of a pre-existing condition, you have options.
Step 1: Verify the Plan Type
First, confirm whether your plan is required to follow ACA rules. ACA-compliant plans must cover pre-existing conditions. Short-term plans, health sharing ministries, and some grandfathered plans may not be required to do so.
Step 2: Get the Denial in Writing
Request a written explanation of why you were denied coverage or charged higher premiums. This documentation is essential for any complaint or legal action.
Step 3: File Complaints
- State Insurance Department: File a complaint with your state's insurance regulator
- CMS: For marketplace plans, file with the Centers for Medicare & Medicaid Services
- Department of Labor: For employer-sponsored plans that violate the law
Step 4: Consider Legal Action
If an ACA-compliant plan is discriminating based on pre-existing conditions, you may have grounds for a lawsuit. This is especially true if you've suffered damages (like denied coverage for treatment you needed).
California law provides additional protections beyond federal requirements. The DMHC and CDI actively enforce pre-existing condition protections. If you're in California and believe you've been discriminated against, file a complaint with:
- DMHC (for HMO/managed care): 1-888-466-2219
- CDI (for PPO/indemnity): 1-800-927-4357
Common Pre-Existing Condition Questions
Can I be denied coverage if I apply during open enrollment?
No. During open enrollment or a special enrollment period, ACA-compliant plans must accept you regardless of your health status. This is "guaranteed issue."
Can insurers charge me more for having a pre-existing condition?
No, not for ACA-compliant plans. They can only vary premiums based on age (within limits), tobacco use, location, and family size. Health status cannot be a factor.
What if I have a gap in coverage?
Under the ACA, there is no penalty for having a gap in coverage, and you cannot be denied coverage or charged more when you re-enroll because of conditions you developed during the gap. This is different from pre-ACA rules.
What about life insurance and pre-existing conditions?
The ACA only applies to health insurance. Life insurance, disability insurance, and long-term care insurance can still deny you coverage or charge higher premiums based on your health history. These products are not covered by the ACA protections.
What if I have employer coverage and switch jobs?
Under HIPAA (Health Insurance Portability and Accountability Act) and the ACA, employer group plans cannot exclude pre-existing conditions. You're protected regardless of how long you've been at your new job.
| Insurance Type | Pre-Existing Condition Protection |
|---|---|
| Health Insurance (ACA-compliant) | Cannot deny or charge more |
| Life Insurance | Can deny or charge more |
| Disability Insurance | Can deny or exclude conditions |
| Long-Term Care Insurance | Can deny or charge more |
| Medicare | Cannot deny (at 65+) |
| Medicaid | Cannot deny |
Protecting Yourself and Your Rights
Always Verify Plan Type Before Enrolling
Before signing up for any health coverage, confirm whether it's an ACA-compliant plan. Ask directly: "Is this plan compliant with the Affordable Care Act?" Get the answer in writing if possible.
Keep Your Medical Records
Maintain copies of your medical records, especially documentation of any pre-existing conditions. This helps if you need to prove that a condition was covered or that you were improperly denied coverage.
Document Everything
If you're denied coverage or believe you're being charged more than you should be, document everything: phone calls (date, time, who you spoke with), letters, emails, and any written communications.
Know Your Enrollment Rights
- Open Enrollment: Usually November 1 - January 15 for individual plans
- Special Enrollment: Triggered by qualifying life events (job loss, marriage, moving, having a baby)
- Employer Plans: Usually have annual enrollment periods set by the employer
Some products are marketed as "health insurance" but don't provide ACA protections. Short-term plans, health sharing ministries, and discount medical plans may look like insurance but can deny you coverage for pre-existing conditions. Always verify what you're buying.
Need Help With a Pre-Existing Condition Denial?
I help individuals who have been wrongly denied health coverage or charged more because of their health history. If you believe your rights have been violated, I can help you understand your options and fight back.