If you’re like most people, you have some kind of preexisting medical condition, whether it’s diabetes or a back injury. Now that the Affordable Care Act, also known as Obamacare, has passed, it might change the way your preexisting conditions are covered by your health plan.
Between 19 and 50 percent of Americans aged between 18 and 64 (at least 50 to 129 million Americans) have a preexisting condition, and about 25 million of those individuals are uninsured, according to the U.S. Department of Health and Human Services.
What is a preexisting condition?
A preexisting condition is a medical condition, disability or illness that you had before you enrolled in a health plan. For example, if you took medication for arthritis last year, then the arthritis is a preexisting condition when you enroll in a plan this year. To be considered a preexisting condition, it does not necessarily have to be a chronic, ongoing or long-term problem. A short-term condition like pregnancy may qualify as a preexisting condition.
Typically, when you apply for coverage, the insurer asks you to identify all medical problems that you’ve had diagnosed or treated, and it checks your records with your previous insurer.
Currently, group plans offered by employers must cover all preexisting conditions. However, if you have an individual plan, the insurance company can deny coverage for preexisting conditions.
Will Obamacare cover my preexisting conditions?
The Affordable Care Act, sometimes called Obamacare, has several provisions that give greater protection to patients with preexisting conditions. Starting on Jan. 1, 2014, insurers will not be permitted to do the following to consumers who have a preexisting condition:
• Deny them coverage.
• Charge them higher prices.
• Refuse to sell them coverage.
In addition, insurance companies are not allowed to cancel coverage due to a mistake or a minor omission on a patient’s insurance application. In the past, they have used this practice, called rescission, to save money by weeding out the sickest and most costly patients. Under the Affordable Care Act, rescission is now illegal except in cases of fraud or intentional misrepresentation on an insurance application. That provision took effect on Sept. 23, 2010.
If you have a preexisting condition, you may benefit from two other provisions of the Affordable Care Act. Starting on Jan. 1, 2014, insurers will be prohibited from imposing annual limits on coverage. Insurers also cannot set lifetime limits on coverage, under a provision to that took effect on Sept. 23, 2010.
For example, let’s say you have a health plan with a $1 million annual cap and a $5 million lifetime cap on the total that the plan will pay. If you need radiation and chemotherapy for breast cancer, you could reach one of those caps quickly and then have to pay the rest of your medical costs out-of-pocket, with no insurance coverage. The new law will stop that from happening.
Without coverage,patients with preexisting conditions often delay treatment, ignore their medical problems or don’t fill their prescriptions because of the cost of health care. More patients might be willing to get the care they need when they know their preexisting conditions are covered under the Affordable Care Act. Ultimately, that could save money if the patient gets the disease or injury treated before it becomes much worse and harder to treat.
High blood pressure, or hypertension, is the most commonly reported preexisting condition that could lead to a health plan denying coverage, requiring higher premiums or restricting coverage, according to the U.S. Government Accountability Office. Second and third highest on the list are mental illness and diabetes. Meanwhile, cancer has the highest annual treatment costs, the GAO reported.
If you ever have a question about whether your preexisting condition is covered, you should call your health plan and ask before you see the doctor or fill a prescription.
If you are healthy right now, the Affordable Care Act’s new protections still apply to you. About 15 to 30 percent of people in good health today are likely to develop a preexisting condition over the next eight years, according to the U.S. Department of Health and Human Services.