Pre-Existing Conditions and how the Affordable Care Act Works for You

By Emily McKinley, Health Information Specialist

With the commencement of the Affordable Care Act (ACA) in 2010, children were granted freedom from pre-existing conditions insofar as health insurance coverage is concerned. Under the law, adults (over 19 years) will enjoy the same coverage beginning in 2014.

The ACA adopted the HIPAA (Health Insurance Portability and Accountability Act of 1995) definition of pre-existing condition, which defines the term “as a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that date.” Conditions previously not covered by insurance providers were wide-ranging and included conditions such as cancers, heart disease, asthma, and wide variety of special health care diagnoses.

Previous to the adoption of the ACA, individuals with a pre-existing condition may have been excluded from insurance coverage altogether; forced to accept policy riders that excluded coverage of services used to treat the condition and/or related dysfunction of organs and body systems; received policies with extreme benefit limits; or were forced to pay higher premiums and more out-of-pocket costs than those without pre-existing conditions.

Now, children can receive the full benefits of health insurance. According to www.healthcare.org, “Plans that cover children can no longer exclude, limit, or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage.” This provision of the ACA is valid for group sponsored plans and all individual plans issued after March 23, 2010. Individual plans purchased before that date may be “grandfathered” and may not include the same protections for individuals with pre-existing conditions.

Furthermore, in 2014, an estimated 129 million Americans under the age of 65 and many senior citizens will be free of pre-existing condition insurance exclusions and rate hikes. At that time, the ACA will usher in the provision that prevents discrimination in the form of exclusions and limits on benefits for adults with pre-existing conditions, and the clause prohibiting health status ratings for the purpose of charging increased premiums will also go into effect.

Until then, adults with pre-existing conditions may look to other sources for insurance coverage. Those sources include the Pre-Existing Condition Insurance Plan ( https://www.pcip.gov/) and Indiana Comprehensive Health Insurance Association (ICHIA) (www.onlinehealthplan.com) coverage. The Pre-Existing Condition Plan should be applied for first as it is less expensive and application to the plan may be a prerequisite for ICHIA coverage. To qualify for the Pre-Existing Condition Insurance Plan, individuals must be a citizen of or lawfully present in the United States, must be uninsured for the previous 6 months, and must have a pre-existing condition or be denied coverage due to a health condition. ICHIA coverage is provided to individuals who are otherwise uninsurable, do not qualify for Medicaid, and are residents of Indiana. Additionally, individuals seeking ICHIA coverage must be federally eligible for coverage, not have access to other health care coverage and/or be eligible for other coverage at a rate higher than the ICHIA premium.

For more about the ACA’s pre-existing condition clauses and other provisions, please visit www.healthcare.gov. To read answers to frequently asked questions regarding enrolling children under 19 with pre-existing conditions in health insurance policies and the protections provided by the ACA, please visit http://cciio.hhs.gov/resources/files/factsheet.html.

If you have questions about how the ACA affects you and/or are interested in speaking with a Health Information Specialist to review insurance and health care financing options with you, please contact Family Voices at 317 944 8982 or info@fvindiana.org.