Does health insurance cover a pre-existing condition?
Since the Affordable Care Act – also known as the ACA or Obamacare – was enacted in 2010, health insurance companies can no longer deny you coverage or charge you more if you have a pre-existing condition.
Under the ACA, health insurance companies also cannot charge women more than men for the same coverage.
Tip: Learn more about the ACA for employers here.
To help you understand how this law affects health insurance companies, employers and employees, we answer some common questions below.
What is a pre-existing condition?
A pre-existing condition is a health condition you had before your coverage started. This may include chronic conditions like asthma, COPD, sleep apnea, diabetes or cancer. Prior to the ACA, health insurance providers could deny people coverage or charge significantly more for a long-term illness.
What’s the bottom line?
- All Marketplace plans through the ACA must cover treatment for pre-existing medical conditions.
- No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had prior to your coverage.
- Once you’re enrolled, your health insurance company can’t deny you coverage or raise your rates based only on your health.
- Pregnancy care and childbirth are covered starting on the day your plan begins.
- If you were pregnant when you applied for coverage, an insurance company can’t reject you or charge you more based on your pregnancy.
Are there any exceptions?
The only exception to the ACA’s pre-existing coverage rule is for grandfathered individual health insurance plans, or those that are through an employer. These plans purchased on or before March 30, 2010, are not required to cover pre-existing conditions or preventive care.
If you have a grandfathered plan and want coverage for pre-existing conditions, you have two options:
- You can switch to a Marketplace plan during open enrollment.
- You can buy a Marketplace plan outside of open enrollment when your grandfathered plan ends, qualifying you for a special enrollment period.
Current Sanford Health Plan members can access their summary of benefits and coverage through our secure member portal or by contacting customer service using the number listed on the back of their member ID card.