Pre-existing condition facts for kids
In the United States, a pre-existing condition is a health problem or illness that a person had before their health insurance plan started. For a long time, some insurance companies would not pay for treatments related to these conditions. This was a way for them to avoid covering people who might need a lot of medical care right away. However, since January 1, 2014, a law called the Patient Protection and Affordable Care Act (often called the ACA or Obamacare) made it illegal for insurance companies to deny coverage or charge more because of a pre-existing condition.
In 2016, about 52 million adults under 65 (more than a quarter of them) had a pre-existing condition.
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What is a Pre-Existing Condition?
A pre-existing condition is simply any health issue that existed before your health insurance plan began. For example, if you had asthma before you got a new insurance plan, that would be a pre-existing condition.
Before the ACA, insurance companies used different ways to decide what counted as a pre-existing condition:
- Objective Standard: This meant a condition was pre-existing if you had already received medical advice or treatment for it before your new insurance plan started.
- Prudent Person Standard: This was a broader rule. A condition was pre-existing if you had symptoms that a "prudent person" (a careful and sensible person) would have sought treatment for, even if you hadn't actually seen a doctor yet.
The rules about which definition could be used varied from state to state.
How Laws Changed Pre-Existing Conditions
The Patient Protection and Affordable Care Act (ACA), which became law on March 23, 2010, brought big changes to how pre-existing conditions were handled.
Immediate Changes (2010)
- High-Risk Pools: Starting in June 2010, special insurance plans called "high-risk pools" were created for people with pre-existing conditions who had been without insurance for at least six months. These plans helped them get coverage.
- Protection for Kids: By September 2010, health insurance plans could no longer refuse to cover children under 19 because of a pre-existing condition.
Major Changes (2014)
- No More Exclusions: From January 1, 2014, insurance companies were completely stopped from denying coverage or charging more for pre-existing conditions in all health insurance plans, for both adults and children.
- Domestic Violence: The law also made sure that insurance companies could not treat situations like domestic violence as a pre-existing condition to deny coverage.
- Waiting Periods: The time you had to wait before your new health insurance plan started covering you was limited to 90 days.
Why Pre-Existing Condition Rules Mattered
Before the ACA, insurance companies sometimes used pre-existing condition rules to avoid paying for expensive treatments. People who had conditions like diabetes, cancer, or even common issues like allergies or acne could be denied coverage or charged much higher prices. This meant many people couldn't get the medical care they needed.
Some people argued that these rules helped keep insurance costs lower for healthy people. However, others argued that it was unfair and left many sick people without access to care.
For example, some insurance companies even considered pregnancy a pre-existing condition, which meant new mothers might not get coverage for their maternity care. The ACA changed this, ensuring that pregnancy is covered.
Common Pre-Existing Conditions
Before the ACA, a wide range of conditions could be considered pre-existing, including:
- Chronic illnesses like asthma or diabetes
- Past cancer
- Heart conditions
- Even minor issues like acne, allergies, tonsillitis, or bunions
- Being a police officer or firefighter (due to higher risk in their jobs)
- Pregnancy
These rules often made it very hard for people with health problems to find affordable insurance.
See also
- Pre-existing Condition Insurance Plan
