Getting health insurance can be challenging enough, but it is even more difficult if you have a pre-existing medical condition. A pre-existing condition is a health issue you had prior to applying for a new health insurance policy. These conditions can range from asthma and diabetes to cancer and heart disease.
Insurance companies often deny coverage or charge higher premiums for individuals with pre-existing conditions. However, there are still options for obtaining coverage.
How Pre-Existing Conditions Affect Health Insurance
Insurers consider conditions that you had prior to applying for a new policy to be pre-existing. This includes conditions that were present but not diagnosed. Insurance companies can deny you coverage outright or exclude coverage for treatment related to your condition or charge you a higher premium.
Some of the most common pre-existing conditions that affect health insurance include:
- Diabetes
- Cancer
- High blood pressure
- High cholesterol
- Asthma
- Arthritis
- Thyroid disorders
- Mental health disorders
- Kidney disease
- Sleep apnea
- Pregnancy
- Obesity
- Heart disease
Having a pre-existing condition does not mean you cannot get health insurance. However, it often takes more effort to find adequate and affordable coverage.
Health Insurance Options for Pre-Existing Conditions
If you have been denied health insurance due to a pre-existing condition, you still have options:
Private Individual Health Insurance
Some private insurers will cover pre-existing conditions, but often with a waiting period before they pay claims related to the condition. You may also have higher monthly premiums. Look closely at policies to understand exclusions and waiting periods.
Group Health Insurance
If you have access to insurance through an employer or other group, this type of coverage cannot deny you due to pre-existing conditions. There may still be some exclusions or waiting periods, but there are more protections and guarantees under group policies.
Government Health Insurance
Government-provided health insurance options like Medicare and Medicaid cannot deny you coverage based on pre-existing conditions. These programs have more robust protections for people with chronic health problems.
High-Risk Pools
Some states offer high-risk pools, which are state-run health insurance programs for people who cannot get private coverage. High-risk pools cap premiums and cannot deny you outright for pre-existing conditions. However, these pools can have long waiting lists due to high demand.
Tips for Finding Coverage
Here are some tips to improve your chances of finding health insurance coverage with pre-existing conditions:
- Carefully research private market plan options: Read the fine print to understand exclusions, waiting periods, and premium costs related to your condition. Individual health insurance plans can vary widely on these factors.
- Check if you qualify for government health programs: Even if you did not qualify in the past, changes in your condition may now make you eligible for Medicare, Medicaid, or special state programs.
- See if a group plan will cover you: Getting insurance through an employer, professional association, or other group often comes with more protections if you have pre-existing conditions.
- Look into state high-risk pools: These pools serve as a backstop if no private insurers will cover you. High-risk pools guarantee coverage but can have long wait lists.
- Consider catastrophic or short-term health plans: While not ideal for managing chronic conditions, these bare-bones plans can provide some coverage if you are in dire need and have no other options.
Major Health Insurance Providers Comparison
Here is an overview of how the major private health insurance companies address pre-existing conditions in their individual market plans:
| Insurer | Coverage of Pre-Existing Conditions | Exclusions/Limitations | Waiting Period |
| Aetna | Will not deny coverage, but may charge higher premiums or exclude some coverage related to your condition | Exclusions depend on condition. Mental health, substance abuse may have limits | At least 12 months for pre-existing condition claims |
| Anthem | Will not deny coverage, but may charge higher premiums exclude some coverage related to your condition | Some plans have 12-month waiting period before covering pre-existing conditions | Range of waiting periods from 0-12 months |
| Blue Cross Blue Shield | Varies by state, but pre-existing conditions usually covered with no denial | In some states, pre-existing conditions not covered for first 6-12 months | Range of waiting periods from 0-12 months depending on state |
| Cigna | Guaranteed issue but pre-existing conditions may affect cost and coverage | Plans available with no exclusions, but highest cost. Other plans exclude coverage for 1 year | Range of waiting periods from 0 months up to 1 year |
| United Healthcare | Guaranteed issue but pre-existing conditions affect premiums and some exclusions | Many exclusions depending on condition, ranging from 1-5 years | Range of waiting periods from 0 months up to 5 years |
As the table illustrates, the major private insurers cannot deny you coverage outright, but pre-existing conditions often come with higher monthly costs and periods where your condition is not covered by the new insurance policy. Always read the plan details carefully.
Government Health Insurance Options Comparison
If private health insurance plans are proving prohibitive due to pre-existing conditions, government-provided coverage often comes with more robust protections:
| Program | Pre-Existing Condition Coverage | Costs | Eligibility |
| Medicare | Fully covered with no exclusions or waiting periods | Low premiums, deductibles, and copays. Part D prescription drug coverage has a coverage gap | Age 65+ or certain disability statuses |
| Medicaid | Fully covered with no exclusions or waiting periods | Minimal to no premiums or out-of-pocket costs | Based on strict low-income requirements |
| ACA Marketplace | Guaranteed issue with no exclusions, delays in coverage | Tax credits available to lower premiums based on income. Out-of-pocket costs vary by plan chosen | Available once per year during open enrollment or with a qualifying event |
Government health programs like Medicare, Medicaid, and the ACA Marketplace do not allow any discrimination based on pre-existing conditions. The coverage comes with low or subsidized rates as well.
Frequently Asked Questions
Can I be denied health insurance because of a pre-existing condition?
No, the Affordable Care Act mandates that health insurance companies cannot deny you coverage outright or charge you more because of a pre-existing condition. However, some waiting periods before coverage takes effect may still apply.
What conditions are considered pre-existing?
Any physical or mental health condition that you had prior to applying for a new health insurance policy is considered pre-existing. This includes common conditions like diabetes, cancer, arthritis, asthma, obesity, kidney disease, and more.
Should I mention my pre-existing condition when applying for health insurance?
Yes, it is important to fully disclose all medical history and conditions to the insurance company. If you do not disclose pre-existing conditions and the insurer later discovers it, they may terminate your coverage altogether.
If I change jobs, will my new health insurer cover my pre-existing condition?
Yes, if you are moving from one group health insurance plan to another, the new insurer cannot apply exclusions, waiting periods etc. based on your pre-existing condition. Protections also apply when moving from group insurance to the individual marketplace.
Can my children get health insurance if they have a pre-existing condition?
Yes. Protections under the Affordable Care Act apply to children and adults equally. Health insurance companies cannot deny coverage to those under 19 years old because of pre-existing conditions.
The Bottom Line
Finding health coverage with a pre-existing condition is challenging but not impossible. Be prepared for higher monthly premiums and periods where care for your condition is excluded by insurers. However, options exist in the private market and government-run health programs that can provide the coverage you need, often at subsidized rates. Do your research and seek expert guidance to secure health insurance despite having a pre-existing condition.
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