Are You Healthy Enough to Get Covered?

Healthcare Policy Expert, Robin Scott, is a contributing blogger for Protestants for the Common Good. 

Do you have diabetes, high blood pressure, or asthma? What about another health problem or condition? If you have a health problem that developed before you join a health insurance plan, you have what a health insurance company calls a pre-existing condition.  It is hard to believe but being pregnant is considered a pre-existing condition.

In the past, in most states, anyone with a pre-existing condition could be discriminated against, meaning they could be denied insurance altogether or their insurance would not cover that condition.   If the condition was covered, they could be charged a higher premium. 

The Affordable Care Act ends discrimination by health insurance plans against people with pre-existing conditions.  Effective September 23, 2010, health insurers are not allowed to deny insurance to children younger than 19 years of age with pre-existing conditions.  This rule applies whether or not the child’s health problem or disability was discovered or treated before you applied for coverage.  (However, this rule does not apply to grandfathered individual health policies.  A grandfathered individual health insurance policy is a policy that you bought for yourself or family on or before the health reform law was enacted.)

Beginning January 2014, health insurers, regardless of whether the plan is grandfathered, will not be able to discriminate against anyone who has a pre-existing condition, including a disability. Not only will they not be able to deny children and adults coverage for a pre-existing condition, they will not be allowed to charge them more for this coverage. 

Millions of Americans are helped by this Affordable Care Act provision. Pre-existing conditions affect people in all age groups, every racial and ethnic group, and every income group.  An estimated 64.8 million (24.9 percent of) non-elderly Americans have been diagnosed with pre-existing conditions that could lead to a denial of coverage. Nearly 2.9 million non-elderly Illinoisans, more than one out of every four residents under the age of 65, have been diagnosed with pre-existing conditions that, absent reform, could lead to a denial of coverage. 

 

Some people have pre-existing conditions now and cannot wait until 2014 to receive help.  Findings from a 2010 national survey found that 36 percent of non-elderly who lost their jobs and benefits and tried to purchase individual health insurance were turned down, were charged more, or had a specific health problem excluded from their coverage.  

What can they do in the meantime?  The Affordable Care Act provides funds for high-risk pools in states for people with pre-existing conditions.  To be eligible, you must meet certain requirements such as being uninsured for six months and be a U.S. citizen or residing in the United States legally.  The pre-existing condition insurance plans cover a broad range of health benefits, including primary and specialty care, hospital care, and prescription drugs.

The federal government runs the PCIP in 23 states and the District of Columbia.  In the other 27 states, the state or a state-designated nonprofit organization runs the program. In Illinois, the Department of Insurance runs the program.  The Pre-Existing Condition Insurance Plan has already provided coverage to at least 82,000 people, including 2,750 people in Illinois (Illinois Pre-Existing Insurance Plan).

 

What if I become sick while I am insured?

Previously, health insurers sometimes rescinded or retroactively cancelled coverage when a person became sick, if the person made an unintentional mistake on their application.  They would state that the person had not listed a pre-existing condition on their insurance application.  The Affordable Care Act changes that – now, insurance companies cannot deny to cover your benefits just because you get sick.  They can only do that in cases of fraud or an intentional misrepresentation of material fact.

An example of an illegal rescission is if the insurance company denies claims for breast cancer treatment when finding out the insured person forgot to mention two visits to a psychologist visit she had six years earlier. http://www.healthcare.gov/law/features/rights/cancellations/

Next to New Mexico, Illinois had the highest rescission rate from 2004 through 2008.  Illinois’ rate was more than 12 per 1,000 certificates or policies from 2004 to 2008.   That’s a total of 5,279 policies/certificates from 2004-2008.  The national rate is 3.7 rescissions per every 1,000 policies or certificates from 2004 through 2008.