What are Pre-Existing Conditions?
A pre-existing condition is any health problem that occurred before enrolling in a health plan. The Affordable Care Act law made it illegal for health plans to or charge more due to a pre-existing condition. This includes Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B)., but not Medicare supplements1HHS.gov, “Pre-Existing Condition“, Accessed September 16, 2021.
Key Takeaways
- Pre-existing conditions are chronic health conditions that exist prior to enrolling in health insurance.
- The Affordable Care Act law prevents health insurers from denying coverage due to a pre-existing condition.
- Without a guaranteed issue right, in most states, Medicare supplement insuranceMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. carriers can deny coverage due to pre-existing conditions.
What Are Some Examples of Pre-Existing Conditions?
A pre-existing condition can be any health condition the beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. had before enrolling in Medicare or other health insurance. However, the term is most often associated with chronic or life-long illnesses like cancer, HIV/AIDS, heart disease, high blood pressure, and even mental health conditions such as depression and schizophrenia2Cigna.com, “What is a Pre-Existing Condition“, Accessed September 16, 2021. Health issues are considered pre-existing if it was diagnosed by a doctor before the date a beneficiary’s health insurance coverage starts, so there is no real difference between pre-existing medical conditions and existing medical conditions to Medicare2Cigna.com, “What is a Pre-Existing Condition“, Accessed September 16, 2021.
What is the Affordable Care Act?
The Affordable Care Act (ACA), sometimes also referred to as Obamacare, is a health care reform law that greatly reshaped how health insurance companies like Medicare and MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. functioned in order to reduce America’s uninsured population3Healthcare.gov, “Affordable Care Act (ACA)“, Accessed September 16, 2021. Among these reforms are guaranteed issue rightsGuaranteed-issue is a right granted to Medicare beneficiaries and applies to Medicare Supplement insurance (aka, Medigap plans). All states and the federal government enforce this essential right, which protects Medicare beneficiaries from medical underwriting., which mandated that people have eligibility for health insurance policies without being denied or charged higher rates due to pre-existing health conditions4Healthcare.gov, “Coverage for pre-existing conditions“, Accessed September 16, 2021.
Why Can I Be Denied Medigap Coverage?
Medigap (Medicare supplement insurance) can deny certain coverage options for pre-existing conditions because it is not health insurance. It is a form of indemnity insurance that covers the risk of a Medicare beneficiary’s out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments.. A Medigap insurance carrier cannot deny coverage when beneficiaries apply for coverage with Medigap protections, also known as guaranteed issue rights5Medicare.gov, “When can I buy Medigap“, Accessed September 16, 2021.
Citations
- 1HHS.gov, “Pre-Existing Condition“, Accessed September 16, 2021
- 2Cigna.com, “What is a Pre-Existing Condition“, Accessed September 16, 2021
- 3Healthcare.gov, “Affordable Care Act (ACA)“, Accessed September 16, 2021
- 4Healthcare.gov, “Coverage for pre-existing conditions“, Accessed September 16, 2021
- 5Medicare.gov, “When can I buy Medigap“, Accessed September 16, 2021