Important Things to Know About Pre-Existing Conditions

Pre-Existing Conditions

Over the last decade, pre-existing conditions have become prevalent in the news due to the ongoing fight over the ACA, and due to recent news that by 2030 around half of Americans will be considered obese. According to a poll, more than one in four Americans suffer from pre-existing conditions, which is around 27% of the U.S. population, and around 17% of people said they live with someone who has a pre-existing condition, thereby around 44% of people living in the U.S. have pre-existing conditions. Now about what is pre-existing condition and how it affects people’s health insurance coverage and their overall well-being.

Understanding Pre-existing Conditions

A pre-existing condition is a long-term or chronic illness such as heart disease, cancer, and diabetes that require regular maintenance or may result in other serious medical issues. Before the year 2010, health insurance companies used to refuse individuals from offering health insurance, if they had a pre-existing condition, or the insurance companies could also charge higher rates depending upon their health condition and gender. However, with the coming up of ACA, health insurance companies were prevented from rejecting individuals with pre-existing conditions for offering health insurance. The health insurers were also prevented to charge more price from individuals having a chronic illness or if they were of a specific gender. Even if the ACA goes away, detractors have agreed that the pre-existing requirement of the law is good for the Americans, and it should be kept in place, no matter ACA plans exist or not.

Health Insurance Options for People with Pre-Existing Health Conditions:

Short-term Health Plan

Normally short-term health plans do not accept individuals having pre-existing conditions, and these plans don’t even pay for medical treatment for pre-existing conditions. However, people who cannot afford health insurance or have to fill a gap then they have some alternative solutions.

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Short-term health insurance or temporary health insurance is a plan offering coverage for as few as 30 days to up to 364 days depending upon their state. Some of the individuals with pre-existing conditions enroll in these short-term plans to fill a coverage gap while waiting for permanent, comprehensive major medical plans.

Short-term plans reject applicants if they have a pre-existing condition, though not all health conditions disqualify them for coverage. Short-term health plans do not accept individuals if they have been diagnosed with any of the following medical conditions:

  • Individuals denied insurance due to any health reason
  • Pregnancy
  • Undergone cancer diagnosis or malignant melanoma
  • Having BMI that is considered obese
  • Heart disorder or abnormal heart rhythm
  • Heart failure, history of heart attack, or stroke
  • Mental disorder
  • Type I diabetes

Though the above mentioned pre-existing conditions are not accepted by the short-term plans acne, sleep apnea, and type-2 diabetes are some of the few conditions that are accepted by many short-term health plans. Individuals if have a medical condition that has evolved due to pre-existing conditions, then their medical claim might not be paid. Individuals if they have an accepted pre-existing condition then they should remember that their insurance carrier might not cover medical treatment correlating with the existing condition. However, they may benefit from repricing. If they are uninsured, they are liable for paying full retail rate and if they have a short-term health plan, then even if their treatment is not covered, their out-of-pocket cost is re-priced to a lower amount, thereby giving them some financial protection.

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ACA Plans

If individuals having pre-existing conditions fall between 100%-400% of the federal poverty guidelines, then the ACA plan is probably the best health plan for them. No medical questions are asked to such individuals because all pre-existing conditions are covered and the plan rates are the same as the healthy person. The rate of the ACA plans varies by state and around 90% of individuals enrolling in the ACA plan receive some form of financial subsidy for their coverage.

Private Major Medical Plans

Individuals who don’t qualify for a financial subsidy on the federal exchange can purchase health insurance through an insurance broker, or directly from a health insurance company. Individuals have more choice when buying off the exchange plan that potentially gives better coverage such as a lower insurance deductible.

Fixed Indemnity Plans

Some of the fixed indemnity plans are guaranteed, and no medical questions are asked to applicants. Though these plans are not ideal for someone with a pre-existing condition, these plans do help lower an individual’s out-of-pocket costs in case of a sudden medical issue.

What to do if Individuals have Pre-existing Condition and need Healthcare

An ACA plan available in the federal marketplace is the best bet for individuals with a pre-existing condition, especially if their household qualifies for a financial subsidy. ACA plan pays for preventive care and not increases premium rates due to an individual’s health circumstances if their pre-existing condition worsens or metastasizes into another issue. Individuals who are not entitled to subsidy due to high household income, then their next option may be a qualifying health plan in the private market. ACA plans can be purchased by anyone on the federal or state marketplaces, but more options are available when individuals buy health plans directly from an insurance company or with the assistance of insurance agents.

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