Does Marketplace Insurance Cover Pre-Existing Conditions? Get the Facts

Could your health insurance claim be denied? For the millions of Americans with pre-existing conditions, this is an important question to ask. Here’s what you need to know about pre-existing conditions and Marketplace health insurance plans.

Understanding Pre-Existing Conditions

A pre-existing condition is any health problem that you have before your health insurance coverage starts. Pre-existing conditions can include anything from sleep apnea to cancer to depression. Even pregnancy can be considered a pre-existing condition.

If you have been diagnosed with a health issue, or if you have received treatment for a health issue, then that health issue can be considered a pre-existing condition when you apply for a new health insurance plan.  

Protections for Pre-Existing Conditions

In the past, it could be very difficult for people with pre-existing conditions to buy affordable health insurance. This was because insurers often used the process of medical underwriting to make coverage decisions, including whether to approve coverage and what the rates should be. Simply put, insurers could deny coverage or charge more based on pre-existing conditions.

However, starting on January 1, 2014, new rules went into effect. These rules include protections for pre-existing conditions. Plans that are subject to these rules must provide coverage for pre-existing conditions and cannot charge more as a result. 

Pre-Existing Conditions and the Health Insurance Marketplace

All Marketplace plans provide coverage for pre-existing conditions. This means that no Marketplace health insurance plan can reject your application, charge you more or deny essential health benefits based on pre-existing health conditions. Additionally, once you enroll in a Marketplace health plan, it cannot raise your rates or deny coverage based on your health.

This protection extends to pregnancy. Marketplace plans cannot charge you more or deny coverage because you are pregnant. Coverage for pregnancy and childbirth begins immediately, with no waiting periods to worry about.

Exceptions to Protections for Pre-Existing Conditions

Although all Marketplace plans must provide coverage for pre-existing conditions, this is not always true of other types of insurance plans.

For example, certain health insurance plans have been grandfathered in, meaning they don’t have to adhere to certain requirements, including protections for pre-existing conditions. As a result, individual health insurance plans purchased on or before March 23, 2010 may not cover pre-existing conditions.

Some other types of non-Marketplace health insurance plans may not provide coverage for pre-existing conditions. This includes certain supplement plans. For example, if you want to purchase a Medicare Supplement Insurance plan, also called Medigap, you can do so during the Medigap open enrollment period that occurs when you first become eligible. After that, plans may be able to deny coverage or charge more based on pre-existing conditions. Short-term health insurance plans may also deny coverage or charge more based on pre-existing conditions.    

Protections for pre-existing conditions typically apply to health insurance and not necessarily to other types of insurance. For example, life insurance, disability insurance and long-term care insurance plans may use medical underwriting to deny coverage or charge higher rates.

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