Does health insurance cover a pre-existing condition?

The Affordable Care Act (ACA) – also known as Obamacare – provides health care coverage protections to people with pre-existing conditions.

Learn how this law affects you below. If you’re an employer, learn what you need to know about the ACA.

What is a pre-existing condition?

A pre-existing condition is a health condition you had before your health care coverage started.

What qualifies as a pre-existing condition?

Pre-existing conditions tend to be chronic, long-term illnesses. Conditions like asthma, COPD, sleep apnea, diabetes and cancer could all be pre-existing conditions.

What does the Affordable Care Act (ACA) say about it?

Before the ACA, health insurance providers could deny people coverage or charge significantly more for a long-term illness. Now, all Marketplace plans through the ACA are required to cover treatment for pre-existing medical conditions.

Under the ACA, health insurance companies also can’t charge women more than men for the same coverage.

Can insurance be denied for pre-existing conditions?

Insurance plans can’t deny you coverage for a condition you had before your coverage.

Pregnancy care and childbirth are also covered starting on the day your plan begins. If you’re pregnant and applying for coverage, an insurance company can’t reject you or charge you more based on your pregnancy.

Can insurers charge more for pre-existing conditions?

Insurers can’t charge you more or refuse to pay for essential health benefits for any pre-existing condition. And after you’ve enrolled, your health insurance company can’t raise your rates based only on your health.

What are some exceptions to pre-existing conditions coverage?

Grandfathered individual health insurance plans are the only exception to the ACA’s pre-existing coverage rule. Plans purchased on or before March 30, 2010, aren’t 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. This qualifies you for a special enrollment period.

Sanford Health Plan is proud of offer ACA health plans in North Dakota and South Dakota. If you’re looking for individual or group health insurance, call us at (888) 501-4560 to connect with an agent, request a quote or email us.

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.

If you’re ready to compare plans for yourself, download our buyer's checklist. You can also call us at (888) 501-4560 to talk to one of our experts and start setting up your plan.


Related Content

The benefits of working with an agent