Does health insurance cover a pre-existing condition?

Thanks to the Patient Protection and Affordable Care Act (commonly referred to as “Obamacare”), which went into effect in 2014, health insurance providers who operate in the United States cannot refuse to cover you or charge you more simply because you have a pre-existing condition. They also can’t charge women more than men for the same coverage.

What’s a pre-existing condition?

A pre-existing condition is a health problem you had before start date of new health coverage. Think chronic conditions like asthma, COPD, sleep apnea, diabetes or cancer. Prior to the ACA, providers could deny people coverage—or charge significantly more for coverage of—such long-term illnesses.

What’s the bottom line?

  • All Marketplace plans through the Affordable Care Act must cover treatment for pre-existing medical conditions.
  • No insurance plan can reject you, charge you more, or refuse to pay for essential health benefits for any condition you had before your coverage started.
  • Once you’re enrolled, the plan can’t deny you coverage or raise your rates based only on your health.
  • Pregnancy is covered from the day your plan starts
    • If you’re pregnant when you apply, an insurance plan can’t reject you or charge you more because of your pregnancy.
    • Once you’re enrolled, your pregnancy and childbirth are covered from the day your plan starts.

Are there any exceptions?

Only exception to the pre-existing coverage rule is for grandfathered (purchased on or before March 30, 2010) individual health insurance plans—the kind you buy yourself, not through an employer. They don’t have to cover pre-existing conditions or preventive care.

If you have a grandfathered plan and want pre-existing conditions covered, you have two options:

  • You can switch to a Marketplace plan that will cover them during Open Enrollment.
  • You can buy a Marketplace plan outside Open Enrollment when your grandfathered plan year ends, and you’ll qualify for a Special Enrollment Period.

If you are looking for individual or group health insurance, contact us at (888) 535-4831 to get in touch with an agent who can help you through the process, or request a quote at https://www.sanfordhealthplan.org/get-a-quote.

Current Sanford Health Plan members can access their SBC and other plan information in their secure member portals at sanfordhealthplan.com/memberlogin or by contacting customer service at the number listed on the back of your insurance member ID card.