What is a pre-existing condition for insurance?

For health insurance, pre-existing conditions are health problems you have before your new health insurance coverage begins. Pregnancy and asthma are common pre-existing conditions. They may also include chronic diagnoses like high blood pressure, diabetes, and cancer; acute issues like a traumatic injury; and resolved problems like a reconstructed joint.

Which health insurance covers pre-existing conditions?

According to the U.S. Department of Health & Human Services, health insurers can't turn you away, charge you more, limit your coverage, or refuse to cover your treatment simply because you have a pre-existing condition. This rule was put in place by the Affordable Care Act in 2014. However, some health insurance plans that were purchased on or before March 23, 2010, are considered "grandfathered" and may not include some rights and protections offered by the ACA. Visit HealthCare.gov to learn more about grandfathered plans that might not cover pre-exisiting conditions.

Which health insurance plans can exclude pre-existing conditions?

In addition to qualifying grandfathered plans, these non-traditional health plans may not be subject to ACA regulations and therefore might not cover pre-existing conditions:

  • Short-term health insurance with an initial term of 364 days or fewer that can't be renewed for a total duration lasting longer than three years
  • Travel insurance with international medical coverage
  • Fixed indemnity plans that have set payouts for specific conditions

Note: Medigap plans, which supplement Medicare but aren't standalone health insurance plans, can't exclude pre-existing conditions if you sign up during the Medigap open enrollment period, but they can impose waiting periods. If you sign up after the six-month open enrollment period, Medigap can use your medical history as a basis for eligibility and pricing unless you meet certain conditions or live in a state with annual Medigap enrollment.

Before you purchase a health-related plan, read the policy's terms and talk with the insurer about coverage for pre-existing conditions.

What about plans that aren't part of my state's government health insurance Marketplace?

If you have health insurance coverage that started in January 2014 or later, it must follow ACA rules about health insurance and pre-existing conditions — even if you bought a private individual or family health insurance plan outside of the government's offerings.

Will health insurance for my pre-existing condition cost more outside of the ACA exchange?

It depends. The ACA Marketplace has subsidies that can help make plans sold through government health insurance exchanges more affordable. Insurance companies that sell outside the exchange need to stay competitive and set their rates accordingly.

To understand your options, you can compare private health insurance quotes to the coverage, prices, and subsidies offered through the government Marketplace.

If you have questions, Progressive® Health by eHealth has a team of dedicated professionals who can help you determine your eligibility and find a health plan that works for you. You can get a health insurance quote online or call 1-888-831-1065.