San Diegans for Healthcare Coverage, A Coalition for Health

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Coverage for Pre-existing Conditions

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.

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.

This section also describes interim provisions already in place for people who cannot find or afford insurance coverage due to one or more pre-existing conditions.

At a Glance

At a Glance

Two interim provisions make it possible for many people with pre-existing conditions to obtain health insurance coverage now: Children’s Pre-existing Conditions and the Pre-existing Conditions Insurance Plan (PCIP).

Click on the following for more information:

Pre-existing Conditions

Pre-existing Conditions Coverage Under the ACA

Most children under the age of 19 and many adults can obtain health insurance coverage for pre-existing conditions now because of ACA provisions that have already been implemented:

  • As of September 23, 2010, insurers are prohibited from denying coverage to children with pre-existing conditions under the age of 19.
  • Until 2014, the Pre-existing Insurance Plan (PCIP) is available to individuals with pre-existing conditions who meet specific criteria. For more information about PCIP, go the section on this website entitled, “The Pre-existing Insurance Plan.”
  • Effective in 2014, health plans can no longer deny coverage or exclude coverage of services due to a pre-existing condition. Coverage under the PCIP will be eliminated, but will be available through the Health Benefits Exchange and on the open market.


Children’s Pre-existing Conditions

Effective September 23, 2010, most individual, group and job-related healthcare plans are required to provide coverage and full treatment benefits for children 0 through 19 years who have pre-existing conditions.

  • Pre-existing conditions CANNOT be excluded from health plans (see exceptions below)
  • 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 individual insurance plans issued or significantly changed after March 23, 2010.

But there are some exceptions:

Exceptions for Group Plans:

Not all group or job-related plans offer coverage for employee dependents (spouse or child). If this is the case for you, then you can purchase an Individual Plan for your child.

If your group or job-related plan does allow coverage for employee dependents but you have not added your child yet, you may have to wait until your annual open enrollment period.

Exceptions for Individual Plans:

Individual plans purchased directly by you may have different requirements. For example, this provision does not apply to “Grandfathered” [insert link to page about grandfathered plans] individual health insurance policies. Grandfathered benefit plans are plans that were in effect on March 23, 2010 and have not made significant changes that reduce benefits or increase member deductibles, copayments or coinsurance.

If your benefit plan is Grandfathered, you have the option of changing plans.  No new individual insurance policy may exclude a child due to a pre-existing condition.

How to Determine if Your Child is Covered

If you have a child who has a pre-existing condition, you will want to determine if your plan must comply or is exempt from this provision. The best option is to discuss your insurance plan with your employer’s benefit administrator or with your insurance company’s membership services department.

Your Options if Your Child is not Covered for Pre-existing Conditions

Don’t be discouraged if your child is not eligible for health insurance under your current coverage. There are a number of options available to you:

  • You may want to shop for a new individual insurance plan for your child since plans sold on the individual market in California must comply with this ACA provision.


The Pre-existing Conditions Insurance Plan (PCIP)

The California Pre-Existing Condition Insurance Plan (PCIP) was established to offer health insurance to California residents who have pre-existing conditions. This program is available now as a result of the federal Affordable Care Act of 2010. For more information click here.

Additional Resources

Additional Resources

State Plans for Pre-existing Conditions

Federal Laws Regarding Pre-Existing Conditions

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