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Pre-existing conditions under 'Obamacare': Your questions answered

by Jaclyn Cosgrove Published: October 22, 2013

Pre-existing conditions are a real concern for an undetermined number of Americans. There isn’t a firm number of how many Americans have pre-existing conditions, as this Politico story points out:

There’s no broadly accepted estimate for how big the problem is. A 2011 study by the Department of Health and Human Services said the number of people with pre-existing conditions could be as low as 50 million non-elderly Americans or as high as 129 million, which is a pretty wide range. But even if you use the lowest number, 50 million, that’s almost one out of five Americans under age 65, including 25 million who are uninsured.

Conservatives don’t think that many people have actually been shut out of coverage. The American Enterprise Institute’s Tom Miller, for example, estimates that only 2 million-4 million Americans have been blocked from getting coverage because of their health. He says a lot of the uninsured people identified by HHS might lack coverage for reasons that have nothing to do with pre-existing conditions.

Over the past few weeks, I’ve been answering questions that several readers have submitted about the Affordable Care Act and how it affects them(And you can still submit questions)

And some of those questions have been about pre-existing conditions, one of the biggest changes under the Affordable Care ActEven though we aren’t sure how many people have pre-existing conditions, there’s definitely an interest in learning how pre-existing conditions work under Obamacare.

Reader’s question: I have a cousin who for years has been unable to get insurance because of a preexisting condition. Now he will be able to be insured depending on what coverage he can afford. Is this correct? He has said that because of his pre-existing condition he still will be without insurance because they won’t cover him.

Answer: Through the health insurance marketplace, your cousin can buy private insurance and can’t be denied based on a pre-existing condition. Under the Affordable Care Act, health insurance plans can’t refuse to cover you or charge you more just because you have a pre-existing health condition. That starts Jan. 1.

There is an exception, though, as the Affordable Care Act website points out:

One exception: Grandfathered individual health insurance plans

The only exception is for grandfathered individual health insurance plans–the kind you buy yourself, not through an employer. They do not have to cover pre-existing conditions.

If you have one of these plans, you can switch to a Marketplace plan during open enrollment and immediately get coverage for your pre-existing conditions.

Also under the Affordable Care Act, children can no longer be denied because of pre-existing conditions, as the U.S. Department of Health and Human Services points out in this article.

  • This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.
  • The new rule doesn’t apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family (and is not a job-related health plan) on or before March 23, 2010.

Reader’s question: Can you explain the new law’s effect on exclusions for a pre-existing condition? Can my existing carrier continue to exclude a condition they have previously excluded on pre-existing grounds?

Answer: If you have what’s known as a “grandfathered health plan,” your carrier can continue to exclude coverage based on a pre-existing condition.

A grandfathered health plan is defined as:

As used in connection with the Affordable Care Act: A group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. Grandfathered plans are exempted from many changes required under the Affordable Care Act. Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions. (Note: If you are in a group health plan, the date you joined may not reflect the date the plan was created. New employees and new family members may be added to grandfathered group plans after March 23, 2010).

 And as this Kaiser Health News article points out, most health insurance plans that existed on March 23, 2010 — the day the Affordable Care Act was signed into law — are eligible for grandfathered status and therefore do not have to meet all the requirements of the health care law.


by Jaclyn Cosgrove
Medical and Health Reporter
Jaclyn Cosgrove writes about health, public policy and medicine in Oklahoma, among other topics. She is an Oklahoma State University graduate. Jaclyn grew up in the southeast region of the state and enjoys writing about rural Oklahoma. She is...
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