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How does Obamacare affect my ability to get health coverage with a pre-existing condition?

As of January 1, 2014, the Affordable Care Act implemented rules that prohibit health insurance companies from charging more, limiting benefits, or denying coverage to you or a dependent because of a pre-existing health condition. And once your coverage begins, the insurer cannot refuse to cover treatment.

If my pre-existing condition does not affect how much an insurer can charge, what can affect my costs?

There are five factors that can increase the cost of your health insurance coverage, primarily through your monthly premium.

  1. Your age can increase premiums (as much as three times for the elderly).
  2. Differences in competition, state and local rules, and cost of living means that your location can affect your costs.
  3. If you happen to use tobacco products, insurers can charge up to 50 percent more than people who do not.
  4. If you have family members labeled as dependents on your insurance policy (spouse or children), you may be charged more than someone who buys a single person policy.

There are five tiers of plans (often called metal levels)—Bronze, Silver, Gold, Platinum, and Catastrophic—that have varying premiums and out-of-pocket costs when you receive care. Platinum plans are designed to have the highest monthly premiums but lowest out-of-pocket costs; Bronze plans are designed to have the lowest monthly premiums but highest out-of-pocket costs.

What Is a Pre-Existing Condition?

A pre-existing condition is a health condition that you’ve been managing before the beginning date of your new health coverage policy. This includes issues such as heart disease, asthma, pregnancy, and cancer.

While you may not have thought of pregnancy as a pre-existing condition, your plan affords coverage for this as soon as it starts. And should you have a baby or adopt a child, you immediately qualify for a Special Enrollment Period, which means you can enroll in or change plans outside of the deadline of the annual Open Enrollment Period (more on this later).

What is covered by health insurance?

Health insurance is a safeguard against accruing crippling debt from receiving health services for an illness, injury, or other condition, including pre-existing conditions. The Affordable Care Act actually lists 10 essential benefits that a comprehensive health insurance policy must cover:

  1. Ambulatory services
  2. Emergency services
  3. Hospitalization
  4. Maternity care
  5. Mental health care
  6. Prescription drugs
  7. Laboratory services
  8. Preventive and wellness services
  9. Pediatric services
  10. Rehabilitative and habilitative services and devices

I know Obamacare affects traditional health insurance policies, but what about Medicaid and CHIP?

Just like a traditional health insurance policy, the ACA prohibits Medicaid and the Children’s Health Insurance Program (CHIP) from denying or charging more for coverage because of a pre-existing condition. 

Are there any exceptions to the new Obamacare rules?

There is one exception to the coverage rule implemented by Obamacare to protect people with pre-existing conditions—a grandfathered individual insurance plan that you’ve purchased yourself, not through your employer. A health insurance plan receives a grandfathered status if its benefits and contribution levels as of March 23, 2010 have not changed in the following ways:

  1. Eliminated or substantially limited benefits for a specific condition.
  2. Increased cost-sharing percentages.
  3. Increased copays by more than $5 or a percentage equal to medical inflation plus 15 percent, whichever is greater.
  4. Increased fixed amount cost-sharing other than co-pays by more than medical inflation plus 15 percent.
  5. Lowered the employer’s contribution rate by more than 5 percent for any grouping of covered persons.
  6. Increased or reduced an annual limit.

If you have a grandfathered plan, you can switch to a new plan that covers pre-existing conditions and meets all other Obamacare requirements. You can accomplish this either through shopping during the Open Enrollment Period, or if your plan ends, this allows you to receive a Special Enrollment Period to receive different coverage.  

What can health insurance companies deny with the new laws in place?

The 10 essential benefits (listed above) must be met by any insurance company. But beyond complying with that requirement, every health insurance provider has the ability to design benefit plans as it chooses, so long as the plan complies with state and federal laws. It is important that you have a firm understanding of the terms in your individual plan and closely follow the rules required by the policy.   

Now that I know my pre-existing condition doesn’t disqualify me, when can I enroll in a policy?

You can purchase coverage during the annual Open Enrollment Period, which runs from November 1, 2015, to January 31, 2016. If you need additional help to enroll for coverage, you can contact a trusted partner like HealthMarkets.

If you miss the Open Enrollment Period, there are specific circumstances that may qualify you for a Special Enrollment Period, allowing you to still acquire a health insurance policy

HealthMarkets Can Be Your Trusted Partner

With over 3,000 licensed agents, HealthMarkets can serve as your trusted partner all-year-round. We offer three simple ways to purchase a health insurance policy.

Purchase online with our user-friendly shopping experience. Before you use the web to buy a plan, consider what prescriptions you get, if you have any pre-existing conditions, if you prefer larger up-front costs (to minimize out-of-pocket expenses), and other needs.

Purchase by phone by speaking with one of our knowledgeable agents. You may want to ask other questions about company options, preferred coverage, and policy metal levels. All you need to do is call us at (800) 360-1402.

Purchase in person through a local agent, so you can get the personal relationship you need to find the policy that’s a fit for you and your family. And with our 3,000 licensed agents, you have plenty of options.

It’s time to get started on finding the coverage you need, and you can do that with HealthMarkets. We know that those with pre-existing conditions often have unique insurance needs, and our team works diligently to review them, meet them, and offer a variety of products from more than 180 insurance companies nationwide. Whether online, by phone, or in person—we can help.


“How Insurance Companies Set Health Premiums.” Healthcare.gov. 2015. | "Catastrophic plan - HealthCare.gov." 2014. | “Coverage for pre-existing condtions.” Healthcare.gov. 2015.

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