What is considered a pre-existing condition and how far does that term go? Is having a c section considered a pre-existing condition? Is depression considered a pre-existing condition?
I’m confused on what is defined as a pre-existing condition. Will the states decide what falls under a pre-existing condition or is everything a pre-existing condition?
It’s any medical condition that you have when you sign up for health insurance.
How that affects future coverage is up to the insurance company and/or any state laws that may apply.
So if a women is sexually assaulted then that could lead to her having a pre-existing condition?
Is there no relief for certain circumstances where a condition is the fault of someone else?
Why would a company care if it’s someone else’s fault? Pre-existing condition exclusion exists to minimize, or decline, payouts in the event of a claim.
This has long been a question of mine about the ACA - how it can possibly be fair for someone to be uninsured, break a leg, buy insurance, and *then *demand that insurance pay for the broken leg.
That’s up to the insurance company. If the assault resulted in a direct injury, that would be pre-existing.
The potential problem is for how long? If you had acne as a teen and you needed treatment for psoriasis twenty years later, does that count? Do you need to disclose the acne even though is been cleared up for twenty years?
Like I said, it’s up to each company and any state laws or regulations.
As an example, California only allows companies to not cover pre-ex. for one year. If you maintain an unbroken record of coverage, then a company can’t refuse treatment if you were being treated under a previous policy.
That’s one of the reasons for the individual mandate. Preventing an exclusion for pre-existing conditions doesn’t work very well if people can hop on and off the plan.
“Adverse selection” is the technical term for that problem, and it’s why health insurance as a pure free market does not work for individuals; it’s also why you CAN get OK health insurance at a reasonable rate from a large employer.
How can irregular periods be a pre existing condition?
Or having a C section?
So, 40 yrs later in life you have further problems, like uterine cancer, then what? Not covered due to pre existing irregular periods or a c section?
Too bad, so sad? There goes the kids’s college fund, the retirement savings and guess you’ll have to sell the house? If that’s the case, it’s seems shockingly harsh!
That seems like craziness to me!
In general, you can’t do that with the ACA. There is a designated sign up period top get insurance. If you miss it, you have to wait until next year. So if you broke your leg just after the sign up period closes, you’d have to wait until next year to sign up for insurance.
Most insurance through work works the same way. There is a certain time for sign ups or plan switching and you have to keep it all year. This is to avoid the employees signing up for the cheapo option and then switching as soon as they get sick.
Ironically, allowing people to sign up at any time with a penalty might make it more likely they will go without insurance. Often, it will be cheaper to go without insurance and then sign up when you need it. Even if you have to pay a penalty, you could have gone years without having to pay for coverage. Then when you break your leg, you sign up and pay the 30% penalty for the few months you need coverage, and then cancel it.
It may seem like craziness to you, but it makes perfect sense to the insurance company.
As Velocity pointed out, the insurance company doesn’t want to sell you a policy right after you broke your leg, just like they don’t want to sell you a homeowner’s policy right after the tornado hit.
Pregnancy was often not covered during the first year of a policy.
But the question is, how long does pre-existing last, and how far does it go? If you have pneumonia as a kid, then you catch it again when you’re 50, does that count as a pre-existing condition? If you’re being treated for diabetes, and you have a heart attack, can the insurance company blame it on the diabetes, and refuse to pay for it?
Conversely, how is it fair to be denied coverage for your pre-existing pregnancy, when what made it “pre-existing” is that your employer decided to change plans?
It seems like the insurance companies interpret it to mean any illness or condition you’ve had in the past, not necessarily something you currently have when you sign up for the plan. For example, a Facebook friend recently posted to her timeline that she learned that her insurance told her that the pink eye she had ten years ago was a pre-existing condition. That’s taking it too far, IMO.
Like I mentioned, (at least in California), if you had continuous coverage, pre-ex. conditions are covered.
Just to elaborate a bit (I work at an ad agency, specifically on health insurance):
The ACA has an “Open Enrollment Period”, or OEP, which, last year, ran from November 1st to December 15th*, during which pretty much anyone under age 65 could sign up for an ACA policy, which would become effective on 1/1/17. (You could, in fact, have signed up as late as January 31st, but your policy wouldn’t become effective until either 2/1/17 or 3/1/17).
Once the OEP ends, most people can’t sign up for an ACA policy until the next OEP begins. However, there is a special, year-round “Special Enrollment Period” (SEP) for people who experience a “Qualifying Life Event” (QLE) – an event which potentially changes their need for insurance.
The major QLEs are:
For most of those QLEs, you have a fairly limited timeframe to sign up under your SEP (usually 30 to 60 days on either side of the date of the event).
Note that “breaking your leg” or “being diagnosed with a disease” are not QLEs.
*
Dying is a pre-existing condition, it begins at birth.
I supposed someone would love to figure out how to play that angle
I got a test for a genetic disorder a few years ago. The test came back negative, but it worries me that the simple act of getting tested might be enough to flag me as having a pre-existing condition.
You just gave the actuaries food for thought
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You might find this interesting.
This kind of legislation seems like it’s increasing fairness, but it’s not so simple. The issue is raised at the end of the article - there is asymmetry of information between the insurer and the purchaser of insurance. Under this legislation, there is apparently nothing to stop a person from getting tested, and if he then finds out he has a life expectancy of 40, buying huge amounts of insurance, which the insurance company is obliged to sell him on the basis that his life expectancy is 70. In other words, the buyer of insurance can legally use the information from genetic testing, but the insurance company cannot.