Will a Pre-Existing Condition Affect My Individual or Family Plan Premium?

Individual and Family

Will a Pre-Existing Condition Affect My Individual or Family Plan Premium?

Published on April 16, 2018


What is a pre-existing condition?

Before diving into how a pre-existing condition could affect your individual health insurance coverage, let’s see what the pre-existing condition definition is.
The Patient Advocate Foundation defines a pre-existing condition as a health problem an individual knew about and had possibly been treated for, before applying for new coverage.
Some examples of pre-existing conditions include:

  • Pregnancy
  • Epilepsy
  • Asthma
  • Sleep apnea
  • Cancer
  • Diabetes

Pre-existing conditions, of course, are not limited to these few examples, and you should make sure to read the specifics of any plan you’re considering to make sure that your plan covers any medical conditions or health problems you have.
Insurance companies used to sometimes charge more or refuse people with pre-existing conditions. This is because more health problems will result in a high-risk pool of members—which means the insurance company was dishing out more money for people who actually used their individual health insurance to its fullest extent.

Do Affordable Care Act (ACA) plans take pre-existing conditions into account?

In the past, pre-existing conditions could pose huge problems for people looking for a new plan. If you had a pre-existing condition, and were looking for a health insurance plan, insurance companies could charge outrageous costs or even deny coverage.
Under current law, insurance companies cannot charge more or refuse coverage due to pre-existing conditions. In 2014, the ACA went into effect, and it was no longer legal for insurance companies to deny coverage for individuals with pre-existing conditions. If you’re buying an ACA-compliant individual health insurance plan, you won’t have to worry about pre-existing conditions you or a family member may have. This does not mean that everything will be covered under your insurance plan. Make sure you read the plan details to see what is covered (regardless of whether it was discovered before coverage under that plan started).

Do non-ACA compliant plans consider pre-existing conditions?

According to healthcare.gov, insurance companies cannot refuse coverage or charge more because of a pre-existing condition, but there are some exceptions to this.
Certain plans, like short-term plans, can reject applicants because of pre-existing conditions. The reason some people may still want these plans, is that they’re often significantly cheaper than ACA-compliant plans. NBC News reported that the current administration has signaled that they plan to extend the amount of time individuals can be covered with a short-term plan. In the past, these plans were limited to 90 days, but it’s possible that they will be extended to 364 days, making them a viable option for some throughout the entire year.

Another exception is that grandfathered plans do not have to cover pre-existing conditions or preventative care, but since these plans are no longer available, you shouldn’t worry about it as someone looking for a new plan.

Will a pre-existing condition result in a higher premium?

Under current law, there should not be any penalty for someone under your policy having a pre-existing condition. If you, or someone under your policy does have a serious health problem, you may end up choosing to buy a plan with a higher premium that allows for more coverage. In that way, a pre-existing condition could result in a higher premium, but only by your choice. You’re not required to choose a certain type of plan depending on health-care needs.
There are still plenty of health insurance options for people with pre-existing conditions. Shopping on the individual market, you may be able to find plans that accommodate your needs and give you the coverage to ensure your medical needs are taken care of.

We’ll let you know when we publish anything new.