Pre-existing Condition Protections under the Affordable Care Act


Author: Kelley Filice Jensen

Beginning 2014, All U.S. citizens and legal residents will have guaranteed health insurance coverage, meaning all discrimination against pre-existing conditions will be illegal, and insurance companies will be prohibited from refusing to sell health insurance or renew policies because of a pre-existing medical condition. Shopping for affordable health insurance? Here are 10 questions to answer before you pick an individual health insurance plan.

What is a Pre-existing Condition and what it means to you?
A pre-existing condition is a medical condition an individual has prior to enrolling for health insurance. Pre-existing conditions can be serious conditions such as: heart disease, diabetes, and asthma, as well as short-term medical conditions like sports’ injuries and/or pregnancy.

According to a January 2011 Department of Health and Human Services report 50-129 million Americans, one out of every other non-elderly person, have some kind of pre-existing health condition.
Prior to the Affordable Care Act (ACA) insurance companies could decide what could be a pre-existing condition and/or: deny you coverage, charge higher premiums, and limit your benefits.

Starting in 2014, all U.S. citizens and legal residents will have guaranteed coverage, meaning all discrimination against pre-existing conditions will be illegal, and insurance companies will be prohibited from refusing to sell coverage or renew policies because of a pre-existing medical condition. In addition, the law will eliminate insurance companies’ ability to charge higher rates due to gender or health status in an individual and small group market. These protections will ensure those with a pre-existing condition will be able to fulfill the individual mandate requirement. Low cost individual insurance plans here

If that is the law, what will stop people from not buying health insurance until they know that they are sick?

Health care reform requires that all Americans to have some form of health insurance, or pay a penalty on their tax returns. This is called the individual mandate, and it was included in the law to balance guaranteed issue.

Will it really be balanced, don’t sick people cost much more than any penalty for not having insurance, is this fair to insurance companies?

It is important to remember that prior to reform, insurance carriers were effectively being charged for the costs of the uninsured through rate increases charged by hospitals. When an uninsured person walks into a hospital and is treated, but cannot pay, hospitals are left with large uncollectible bills. Those uncollectibles go into the rates they charge for services.

What to do before 2014?
Pre-Existing Condition Insurance Plan (PCIP)
Up until 2014, the Pre-Existing Condition Insurance Plan (PCIP) makes health insurance available to those that have been denied coverage by private insurance companies due to a pre-existing condition. The PCIP presently serves as a transitional bridge when the present pre-existing conditions protections for children under 19 extend to all Americans.

Am I eligible for PCIP?
Person applying for PCIP coverage must be:
-A U.S. citizen or legally residing in the U.S.
-Presently living in one of the 50 states or the District of Columbia
-Have been without health coverage for at least 6 months before applying
-A pre-existing medical condition or have been denied coverage because of a health condition
You are not eligible for PCIP if you:
-Have other insurance coverage, even if it does not cover your medical condition
-Enrolled in a state high risk pool
-Have a limited benefits plan
-Have Medicare,  Medicaid, CHIP, VA, TRICARE coverage
-Have job based coverage, including COBRA  or continuing coverage, even it is about to end
Premiums and determining pre-existing conditions vary depending on state, age, and health plan you choose. Enrollees may be responsible for paying deductible and cost-sharing expenses.
PCIP eligibility is not based on income.

What documentation does PCIP require to determine whether I have a pre-existing condition?
When applying for federally-run PCIP you are required to provide at least one of these documents to prove eligibility:
– A denial letter from an insurance company for individual insurance coverage, not health insurance offered through a job, dated within the past 12 months. Or, you may provide a letter dated in the past 12 months from an insurance agent or broker licensed in your state that shows your ineligibility for individual insurance coverage from one or more insurance companies because of your medical condition. The denial letter must include:
-Insurance company denial letter with:
-Your first and last name
-Name of licensed insurance company on official letterhead,
-A statement that you are not eligible for coverage due to your pre-existing condition
-Agent broker denial letter with:
-Your first and last name,
-Name and business address of the agent or broker’s insurance agency,
-Agent or broker’s state producer license number,
-Name of at least one insurance company that has, or would have denied your health coverage due to a pre-existing condition,
-A statement that you are not eligible for insurance company’s coverage due to your pre-existing condition
-An offer of individual insurance coverage, not health insurance offered through a job, dated within the past 12 months that you did not accept as it did not cover your medical condition. This offer of coverage must have a rider that says your medical condition won’t be covered if you accept the offer. The offer letter with a rider must include:
-Your first and last name
-Name of the insurance company on official letterhead
-A rider with an effective date, and a date when it expires or can be removed
-A statement that the rider won’t cover your specific medical condition
NOTE: Even if you currently have insurance coverage that doesn’t cover your specific medical condition, you are not eligible for the PCIP. Some states and non-profits fund their own PCIP. These states’ application procedures, and cost and benefits may vary.
PCIP covers the following benefits:
-Hospital inpatient and outpatient services
-Mental Health and substance abuse services
-Professional services for the diagnosis or treatment of an injury, illness, or condition
-Home health and hospice services
-Noncustodial skilled nursing services
-Durable medical equipment and supplies
-Diagnostic X-rays and laboratory tests
-Physical therapy services
-Emergency and ambulance services
-Prescription drugs
-Preventive and Maternity care
PCIP cannot provide the following:
-Cosmetic surgery or other treatment for cosmetic purposes except to restore bodily function or deformity correction resulting from disease
-Custodial care except for hospice care associated with palliation of terminal illness
-In vitro fertilization, artificial insemination, or any other artificial means to cause pregnancy
-Abortion services except when the mother’s life is endangered or pregnancy result of rape or incest
-Experimental care except as part of an FDA-approved clinical trial

For more information about PCIP visit:
Call PCIP Customer Service at:
1-866-717-5826 (TTY: 1-866-561-1604)
Monday – Friday, 8 a.m. to 11 p.m. EST


At Risk: Pre-Existing Conditions Could Affect 1 in 2 Americans

PPC’s Guide to Health Care Reform available at:

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2 Responses to “Pre-existing Condition Protections under the Affordable Care Act”

  1. homepage says:

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    • sguy says:

      Hi, Thank you for the nice comments and taking the time to write. I apologize for the delay in getting back to you. Not sure why you are having a problem. Just tested the site in IE 10,9,8,7,6 on Win7 down to XP and I’m not seeing any overlap issues. Perhaps your browser needs to restart? If the issues continue, let us know what version of IE and OS you are using and we’ll investigate further.

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