Pre-existing conditions
You may have heard the term pre-existing condition. It’s a term that can come up in relation to getting health care. So, what exactly does it mean? Put simply, a pre-existing condition is a health issue you had before your current health plan started — examples could be asthma, diabetes or even pregnancy.
Years ago, having a pre-existing condition may have made it harder to get health insurance. But today, that’s changed. The Affordable Care Act (ACA) may allow you to get the coverage you need without facing higher costs or delays.1
Let’s walk through the basics — and go over what pre-existing conditions may mean for you and how you choose your health plan.
What are pre-existing conditions?
Pre-existing conditions are health conditions you had before your health insurance coverage started. This could include long-term issues like diabetes or high blood pressure or even temporary ones like an injury or surgery.1
These conditions can be:
- Physical or mental health conditions
- Diagnosed or undiagnosed
- Ongoing or resolved
It doesn’t matter if you received a formal diagnosis or simply asked about or went in for treatment — that history can still count as pre-existing.
How are pre-existing conditions determined?
Insurance companies typically look at your health history to identify pre-existing conditions. This may include:
- Your medical records
- Prescriptions
- Doctor visits
- Past treatments or diagnoses2
They may look back several months or even years — it varies by health plan. But here’s the important part: if you’re shopping for an ACA-compliant plan, this history legally cannot be used to raise your rates or deny your coverage.3
Health coverage for pre-existing conditions
You may be wondering about how health insurance works for pre-existing conditions — or if you may be subject to a waiting period if you have a pre-existing condition. The good news is with an ACA-compliant plan, you’re not. Marketplace plans and most job-based health plans must cover care for pre-existing conditions right away. That means there are no waiting periods before you can get care related to those conditions.1
Some short-term health plans or non-ACA plans may still include waiting periods — or may not cover pre-existing conditions at all. Be sure to read the details before you enroll in a plan.
Can I be denied coverage if I have a pre-existing condition?
No. Under the ACA, it’s against the law for a health insurance company to deny you coverage because of a pre-existing condition.2
This protection applies to:
You also can’t be charged more just because of your health history.
What to know about pre-existing conditions when you’re choosing a health insurance plan
If you’re managing a health condition — or have in the past — choosing the right plan matters. Some plans offer extra benefits or care management programs that may help support your health.
ACA plans and pre-existing conditions
ACA-compliant plans must:
- Cover treatment for pre-existing conditions
- Offer essential health benefits like preventive care, hospital visits and prescription drugs
- Provide coverage from day 13
These protections apply whether you get your plan through Healthcare.gov, a state exchange or directly from a licensed insurance provider.
Other insurance plans and pre-existing conditions
Not all plans follow ACA rules. Plans like short-term health insurance or limited benefit plans may:
- Deny you coverage based on your health history
- Exclude certain conditions from coverage
- Require a waiting period
If you’re considering one of these plans, check carefully to see how pre-existing conditions are handled.2
Find the right health insurance plan for your situation
Having a pre-existing condition shouldn’t stop you from getting the care you need. If you’re shopping for coverage, look for a plan that fits your health needs — and supports the care that matters most to you.
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