Can I get ACA coverage if I have pre-existing conditions?
Will the ACA marketplace deny me coverage because of pre-existing health conditions?
No, the ACA Marketplace cannot deny you coverage or charge you more based on pre-existing health conditions. The Affordable Care Act (ACA) includes protections that ensure everyone, regardless of their health history, has access to comprehensive health insurance. Here’s what you need to know about how the ACA handles pre-existing conditions:
1. No Denial of Coverage for Pre-Existing Conditions
Under the ACA, insurance companies that offer plans through the Marketplace are required to accept all applicants, regardless of any pre-existing health conditions you may have. This means:
Pre-existing conditions include any health issues you had before applying for health insurance, such as diabetes, asthma, cancer, heart disease, mental health conditions, and pregnancy.
You cannot be denied coverage based on your medical history or current health status.
2. No Higher Premiums for Pre-Existing Conditions
In addition to guaranteeing coverage, the ACA also ensures that individuals with pre-existing conditions are not charged higher premiums because of their health status. Insurers cannot:
Increase your monthly premiums based on any pre-existing condition you have.
Base your premium costs on health factors like chronic conditions or previous medical treatments.
3. Comprehensive Coverage of Essential Health Benefits
All ACA Marketplace plans are required to cover a set of essential health benefits, which include services related to treating pre-existing conditions. These benefits include:
Ambulatory services (outpatient care).
Hospitalization.
Prescription drugs.
Maternity and newborn care.
Mental health services and substance use disorder treatment.
Preventive care (such as screenings, immunizations, and chronic disease management).
This means that once you’re enrolled in a Marketplace plan, your pre-existing condition is covered under the plan’s essential health benefits.
4. No Waiting Period for Coverage
ACA Marketplace plans must cover pre-existing conditions immediately, with no waiting period. This means that as soon as your health insurance coverage starts, any care or treatment related to your pre-existing condition will be covered without any delays.
5. Protections for Pre-Existing Conditions in All ACA Plans
These protections apply to all ACA-compliant health plans, including:
Marketplace plans (Bronze, Silver, Gold, and Platinum levels).
Plans purchased outside of the Marketplace, as long as they meet ACA standards.
Short-term health plans, however, do not have to follow ACA rules, and they may exclude coverage for pre-existing conditions. Be cautious when exploring short-term or non-ACA compliant plans.
6. What About Pregnancy?
Pregnancy is considered a pre-existing condition, and under the ACA, all health insurance plans sold through the Marketplace are required to cover maternity and newborn care. This means:
You cannot be denied coverage if you’re pregnant when applying for a Marketplace plan.
Maternity and newborn care will be covered as part of your plan’s essential health benefits.
7. Pre-Existing Condition Coverage for Children
The ACA’s protections extend to children as well. If you’re applying for a plan for your family, your child cannot be denied coverage or charged more based on any pre-existing condition they may have.
8. Special Enrollment Periods and Pre-Existing Conditions
If you qualify for a Special Enrollment Period (due to a life event such as losing coverage or moving), you can enroll in a Marketplace plan outside of the Open Enrollment Period. Your pre-existing conditions will still be covered immediately, and there will be no waiting periods or denials due to health conditions.
Key Takeaways:
The ACA Marketplace cannot deny you coverage or charge you higher premiums because of pre-existing health conditions.
Coverage for pre-existing conditions starts immediately once your plan becomes active, with no waiting periods.
ACA plans cover essential health benefits, including treatments related to your pre-existing condition.
For personalized guidance or help enrolling in a Marketplace plan, schedule an appointment with a Tsunami Advisor here: Schedule an Appointment.
