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How does the Affordable Care Act affect your ability to get health insurance for pre-existing conditions?

The Affordable Care Act (also known as the ACA) protects those with pre-existing conditions. The law prohibits plans sold on the ACA marketplace 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, ACA-qualified plans must cover your treatment.

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 insurance policy. This includes issues such as diabetes, asthma, 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.

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

  1. Your age can increase premiums (as much as three times for older enrollees).
  2. Your location can affect your costs due to differences in competition, state and local rules, and cost of living.
  3. Your tobacco product use—insurers can charge up to 50% more for people who smoke.
  4. Family plans may be charged more than someone who buys an individual 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 else is covered by ACA-qualified health plans?

The Affordable Care Act 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

What about Medicaid and CHIP coverage of pre-existing conditions?

The ACA also 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 Affordable Care Act rules?2

One exception to the coverage rule implemented by the ACA to protect people with pre-existing conditions are “grandfathered” plans, which is individual health coverage purchased before March 23, 2010. These plans are not required to protect pre-existing conditions or cover preventive care.

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.  

Do all health plans have pre-existing coverage protections?

No, not all health plans cover pre-existing conditions. Health plans that do not comply with ACA standards, such as short-term coverage can deny coverage based on your health history. 

When can I apply for an ACA-qualified health plan?

You can purchase health coverage during the annual Open Enrollment Period, which usually runs from November 1 to December 15 in most states. Check your state’s enrollment dates here.

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 policyIt is also possible for federal or state governments to declare special enrollment periods outside of the Open Enrollment Period.

HealthMarkets Can Help You Find a Plan

HealthMarkets can help you review your options when it comes to health insurance for pre-existing conditions. We can help you find coverage that works for your needs and budget. Start comparing available plans in your area today.


1. Healthcare.gov. Retrieved from https://www.healthcare.gov/how-plans-set-your-premiums/. Accessed July 8, 2021. | 2. Healthcare.gov. Retrieved from https://www.healthcare.gov/coverage/pre-existing-conditions/. Accessed July 8, 2021. | 3. Healthcare.gov. Retrieved from https://www.healthcare.gov/blog/open-enrollment-2021-dates/. Accessed July 8, 2021. 

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