What is a pre-existing condition and how does it work with insurance?

Part 2 includes an expanded refresher plus addressing the potential COVID-19 impacts.

In Part 1 of this two-part series, we outlined the definition of a pre-existing condition.

Definition: Most insurance companies use one of two definitions: “Objective standard” definition, a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan (Think job change). Under the broader “prudent person’ definition, a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.

Before ACA/Obamacare: Which definition may be used was sometimes regulated by state law. Ten states did not specify either definition, 21 required the ‘prudent person’ standard and 18 required the ‘objective standard.’ Every state, every insurance plan could make its own determination. Prior to the ACA, there were no insurance industry-wide pre-existing protections.

The Patient Protection and Affordable Care Act (also known as Obamacare) was enacted March 23, 2010. It included a delayed rollout period that allowed for grandfathering in of some exclusions. However, effective Jan 1, 2014, full enactment included for individual and group health insurance plans the prohibiting of pre-existing condition exclusions in all health insurance plans. Prohibited all exclusions, waiting periods, and conditions — no exceptions.

The 10 most common diagnoses are diabetes, acne, anxiety, asthma, sleep apnea, depression, pregnancy (when changing health insurance), cancer, heart conditions and COPD. Other common conditions are extreme obesity, lupus, celiac/autoimmune disorder/gluten sensitivity, high blood pressure and any medical injury or illness that you had before you started a new health plan.

With over 134 million Americans with pre-existing conditions, the ACA/Obamacare’s protections are significant.

COVID-19 has identified a new group of pre-existing conditions. With the ever-growing number of COVID-19-infected patients, the impact of their long-term health effects is still being determined. New numbers also include over five million children infected with COVID since the onset of the pandemic. What will be their long-term health impact? Pre-existing protection for this new group is a new dynamic in the pre-existing protection category.

The term “Long Haulers” speaks directly to people who have had COVID and have new, long-term or short-term health impacts following the initial diagnosis. These people will have new healthcare bills and a new list of “potential pre-existing conditions.”

Without the protection of the ACA/Obamacare, an insurance plan or employer-sponsored plan could exclude these new costs. This pre-existing protection continues.