Healthcare Coverage with a Pre-Existing Condition - Healthpocket

Pre-Existing Medical Conditions

The Affordable Healthcare Act (ACA) mandates that, beginning in 2014, health insurance companies must sell ACA plans to everyone regardless of pre-existing medical conditions. This requirement does not apply to Term Health Insurance plans which are not regulated under the Affordable Care Act. For more information on Term Health Insurance plans, see the article "What Is Term Health Insurance?" A pre-existing medical condition is a health problem (e.g. a disease) that an individual has before applying for a new health insurance plan. Before the ACA coverage mandate, individuals with pre-existing conditions could be charged higher insurance rates or be denied health coverage entirely.

Common pre-existing conditions include, but are not limited to, the following:

  • Arthritis
  • Asthma
  • High cholesterol
  • Hypertension (High Blood Pressure)
  • Diabetes

Pre-Existing Condition Statistics

As many as 129 million Americans have a pre-existing condition and 25 million of them are uninsured. Statistics published by the government predict that 15% to 30% of individuals who are currently healthy will develop a pre-existing medical condition in the future. (

Pre-existing conditions come in a variety of forms. For some, it is a cancer that is in remission that no longer affects daily activities but for others it is a chronic health problem such as asthma or diabetes. Research has found that workers with chronic health problems are 40% less likely to leave their current jobs or go into business for themselves because they are unable to change healthcare providers due to the risk of being denied coverage because of a pre-existing medical condition. (

For some individuals with pre-existing medical conditions, changing health insurance plans was forced upon them. Life events such as divorce or retirement triggered a need for new health insurance and resulted in application rejections. For other individuals, an health insurance denial occurs not for them but for a child in their family. Approximately 5% of children have pre-existing conditions. Somewhere between 4 million and 17 million children under the age of 18 fall into this category and 2 million are uninsured as of 2012.(

Until 2014, when insurance companies will be mandated to accept applicants with pre-existing conditions, consumers have been provided with temporary coverage options by the Pre-Existing Condition Insurance Plan (PCIP). The PCIP was designed to make health coverage options available to people with pre-existing conditions. In some states the program is run by the U.S. Department of Health and Human Services and in other states, it is run by the state government or other non-profit organizations. PCIP eligibility and coverage amounts vary from state to state. Generally major medical and prescription drug expenses are included but enrollees are responsible for paying out-of-pocket for premiums, deductibles, copayments, and coinsurance amounts. As of April 2012, 67,482 Americans have enrolled in these plans. (

After the ACA mandate takes effect, the PCIP program will no longer be available, but enrollees will be provided with information on coverage options before the transition takes place.

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