Coverage for Pre-Existing Conditions
One of the central goals of health reform is to provide all Americans, even those with pre-existing conditions, access to affordable health insurance. As of 2014, the Affordable Care Act (ACA) ensures that health plans will no longer be able to deny or exclude health insurance coverage because of a pre-existing condition. A pre-existing condition is a condition, disability or illness (either physical or mental) that existed before you applied for health insurance. Historically, many people with pre-existing conditions have either been denied health insurance or have had their pre-existing conditions excluded from their health insurance coverage.
Group Health plans for large employers (51or more employees) may exclude coverage for certain services for pre-existing conditions but only for a limited time and only for conditions that have been diagnosed and/or treated within the six months immediately preceding your employee’s application.[i] Under California law AB1672, small employers (2 to 50 full-time employees) are guaranteed group coverage should they choose to purchase it, regardless of the employees' health status.[ii]
At a Glance
As of July 1, 2014, the Affordable Care Act (ACA) ensures that health plans will no longer be able to deny or exclude health insurance coverage because of a pre-existing condition.
This section provides an overview regarding Group Health plans and coverage of pre-existing conditions.
Click on the following for more information:
- Requirements of Group Plans to Cover Pre-existing Conditions
- The ACA Provision for Children’s Pre-existing Conditions
- Additional Resources
Group Plan Requirements
The requirements for Group Health Plans differ for small and large employers:
Small Employers (2 to 50 full-time employees)
Today, California state law AB1672 says that small employers cannot be denied coverage for any reason as long as they:
- Pay their premiums
- Have been in business longer than two months
- Offer medical insurance coverage to all eligible full- and part-time employees
- Comply with insurer requirements regarding employer contribution and employee participation
- Have not committed fraud against the insurer
Under California law AB1672, small employers (2 to 50 full-time employees) are guaranteed group coverage should they choose to purchase it, regardless of the employees' health status. Insurance companies are not allowed to ask about genetic test results or the family history of eligible employees and their dependents during the application process. Under no circumstances can employers be turned down or charged more because of the genetic information or family history of someone in the group.
Large Employers (51 or more employees)
Group Health plans for large employers may exclude coverage for certain services for pre-existing conditions but only for a limited time and only for conditions that have been diagnosed and/or treated within the six months immediately preceding your employee’s application. The following list describes protections against unfair exclusion of pre-existing conditions. These protections may vary depending on the type of group health plan you belong to:
- A group health plan can count as pre-existing conditions only those conditions for which you actually received (or were recommended to receive) a diagnosis, treatment or medical advice within the 6 months immediately before you joined that plan. This period is known as the “look back” period.
- Group health plans cannot apply a pre-existing condition exclusion period for pregnancy, newborns, newly adopted children, children placed for adoption, or genetic information.
- Group health plans can exclude coverage for pre-existing conditions only for a limited time. The maximum exclusion period depends on the type of group health plan you are joining. If you are joining a fully insured group health plan in California, the maximum exclusion period is 6 months. If you are joining a self-insured group health plan, the maximum exclusion period is 12 months. You will receive credit toward your pre-existing condition exclusion period for any previous continuous coverage.
- If an employee enrolls late in your group health plan (after they are hired and not during a regular or special enrollment period), there may be a longer pre-existing condition exclusion period. A late enrollee in a self-insured group health plan may face a pre-existing condition exclusion period up to 18 months. A late enrollee of fully insured group plan may face a pre-existing exclusion period up to 12 months.
- Group health plans that impose pre-existing condition exclusion periods must give you credit for any previous continuous creditable coverage that you’ve had. Most types of private and government sponsored health coverage are considered creditable coverage.[iii]
Requirements for Children’s Coverage
Effective September 23, 2010, most group and employer-sponsored healthcare insurance plans are required to provide coverage and full treatment benefits for children under the age of 19 who have pre-existing conditions if the employer offers dependent coverage.
- Pre-existing conditions CANNOT be excluded from insurance coverage.
- Treatment of pre-existing conditions CANNOT be limited (for example, the insurer cannot refuse to pay for chemotherapy for a pre-existing cancer diagnosis)
- This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.
- This rule applies to most job-related, group insurance plans and for many individual insurance plans issued or significantly changed after March 23, 2010.
But there are some exceptions. For more information, go to the section on this website entitled, “Coverage for Pre-existing Conditions.
If you have employees who are not eligible for coverage under your group plan, and are struggling to obtain coverage for a pre-existing condition, they should know about two interim ACA provisions that may make it possible to obtain individual health insurance coverage. Please direct them to these two sections on this website:
Use the Insurance Finder Tool to compare and contrast group health plans available in your area for your business:
Healthcare.gov – Insurance Finder Tool