Health Insurance With Pre-Existing Conditions: Your Questions Answered
The Gist
Prior to the passage of the Affordable Care Act (ACA) in 2010, health insurance companies were allowed to deny coverage or charge higher premiums for people with pre-existing conditions.
Pre-existing conditions are defined as any health issue — like asthma, pregnancy, or cancer — that you had prior to your new health coverage beginning.
Thanks to the ACA, health insurance companies are no longer allowed to charge more or deny coverage to people based on pre-existing conditions.
This applies to all health plans available to Americans, not just ACA marketplace plans.
Medicaid and Children's Health Insurance Program (CHIP) plans were also impacted by the ACA — if you qualify, you can’t be denied coverage based on pre-existing conditions.
It’s important to shop around for the best plans that suit your health care needs, especially since certain ACA marketplace plans could be partially subsidized, saving you money on your monthly premiums.
In This Article
Are There Any Exceptions Where I Could Be Denied Health Insurance With Pre-Existing Conditions?
Did The Aca Change Any Rules About Medicaid And Pre-Existing Conditions?
What’s The Best Way To Shop For Health Insurance With Pre-Existing Conditions?
In Short
Shopping for a health insurance policy can get overwhelming. But believe it or not, up until fairly recently, it was even more of a headache, especially for people with pre-existing conditions.
Studies, including one conducted by the Kaiser Family Foundation, have shown that over 25 percent of Americans have what could be classified as a pre-existing condition, like asthma, cancer, or chronic illness. Prior to the ACA becoming law in 2010, health care companies were allowed to deny coverage or charge higher premiums to people shopping for health insurance with pre-existing conditions.
Thanks to the ACA, there are relatively few barriers to obtaining health insurance. It’s important to know all the options available and to shop around for the best plan to suit your income level and health care needs.
Whether you’re shopping for a new plan or just looking to see if there’s a way to lower your monthly premiums, you can rest assured that you’ll be able to get health insurance with pre-existing conditions.
What Is a Pre-Existing Condition?
As we mentioned above, according to the Kaiser Family Foundation’s 2019 study, nearly a quarter of Americans have what could be classified as a pre-existing condition. Pre-existing conditions are defined as any health problem or issue that began prior to your new coverage beginning.
Common pre-existing conditions include:
Pregnancy
Epilepsy
Depression
Asthma
Heart disease
Sleep apnea
Anxiety
Cancer
Lupus
Diabetes
Acne
Prior to the implementation of the ACA, people with these pre-existing conditions would have to purchase coverage at higher premiums from what was referred to as a “high-risk pool.” Fortunately, you can no longer be denied health insurance with pre-existing conditions.
If affordability is an issue, make sure you shop around. Depending on your income level, ZIP code, and health conditions, you might be eligible for a subsidized plan where the state or federal government covers some or all of your monthly premium.
Can I Get Health Insurance With a Pre-Existing Condition?
Yes! You can get health insurance with pre-existing conditions. Not just that, but as we mentioned above, thanks to the ACA, insurers can no longer deny coverage or charge you higher premiums based on pre-existing health issues.
Protection for people with pre-existing conditions was one of the main goals of the legislators who crafted the ACA — aside from, as the name implies, giving more Americans access to affordable care. That means you could save big on out-of-pocket expenses that, prior to the ACA, could have really started to add up.
With these rules, consumers also have access to more choices when shopping for health care coverage. Whether you’re looking to buy directly from a private insurance company or you’re shopping for an ACA plan through a Marketplace or Exchange, you still cannot be denied coverage. This is great news for anyone with a pre-existing condition who is looking to save on their health care costs.
And if you want to see all the plans available to you at once (including ACA and private insurance), Stride Health is here to help. Simply enter your ZIP code and provide some basic health information and we’ll recommend plans that best suit you — compare and contrast your options with just a few clicks!
It’s important to remember that ACA plans can only be purchased during the program’s Open Enrollment Period. For 2024, the ACA’s Open Enrollment Period is from November 1, 2023, to January 15, 2024. You may also qualify for a Special Enrollment Period if you have recently experienced a Qualifying Life Event, like losing your job, getting married, or having a baby.
Are There Any Exceptions Where I Could Have Higher Premiums or Be Denied Health Insurance With Pre-Existing Conditions?
Unfortunately, there are a few exceptions to the ACA, but they are relatively specific cases. The two types of health insurance plans that can deny coverage to people with pre-existing conditions are:
Short-term insurance plans: These are special plans that can be purchased at any time of the year (outside of open enrollment or special enrollment periods) and are typically used as a stopgap for anyone with a lapse in coverage. Because of the special nature of these plans, you can be denied coverage or charged higher premiums if you have a pre-existing condition.
Grandfathered plans: Any group health plans that were in place before March 23, 2010, are grandfathered in, which means that it is allowed to follow the old rules by virtue of the fact that the policy was in place before the ACA became law. Now that it’s 2023, these are becoming increasingly rare, but there might be some holdouts. If you are shopping for a new plan, this should not be an issue.
As we mentioned above, insurance companies are not allowed to charge you a higher monthly premium for your policy because of pre-existing conditions. They are, however, allowed to raise premiums in certain situations, for instance:
Age: How old you are can impact the cost of your premiums.
Where you live: Plans can cost more or less based on your state or city of residence.
If you smoke: Insurers can increase premiums by as much as 50 percent if you’re a smoker.
If you’re adding family members to your plan: Partners, children, and other dependents can impact your monthly premiums.
Did the ACA Change Any Rules About Medicaid and Pre-Existing Conditions?
Yes! The ACA also made a big change to Medicaid and Children's Health Insurance Program (CHIP) plans. As long as you qualify for those programs, you can’t be denied coverage based on pre-existing conditions.
Medicaid and CHIP plans are available to people who meet income thresholds as defined by their state, such as:
Families and children
Pregnant people who lack insurance
The elderly
People with disabilities
Medicaid and CHIP availability and eligibility vary by state, but one thing is true in all 50 states: You can’t be denied Medicaid or CHIP coverage because of your pre-existing conditions.
Another change to Medicaid that came with the ACA is that the law established a uniform standard for financial eligibility. Financial eligibility for Medicaid is now based on modified adjusted gross income (MAGI). MAGI is defined as your adjusted gross income after certain deductions, like the Child Tax Credit and student loan interest.
Most tax preparation software should be able to help you calculate your MAGI, which can help determine your eligibility for Medicare, Medicaid, and ACA subsidies that can help make your premiums more affordable.
What’s the Best Way to Shop for Health Insurance With Pre-Existing Conditions?
As you now know, thanks to the ACA, it is no longer legal for health insurance companies to deny coverage or charge higher premiums for people with pre-existing or chronic health conditions. This is great news for anyone buying their first insurance plan, especially if you’ve been putting it off because you were worried that your health situation might cause headaches during the process.
Stride suggests various insurance plans to make sure you’re getting the coverage that best suits your income level, budget, and health care needs. Remember, you can not be denied coverage based on your pre-existing conditions.
If you’re ready to start shopping, enter your ZIP code below. Within seconds you’ll see every plan available to you. Then, you can use our easy-to-understand comparison tools to figure out which coverage is right for you and/or your family.
