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How Does the Health Care Reform Law Affect People With a Pre-existing Condition?

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Updated February 26, 2013

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

Question: How Does the Health Care Reform Law Affect People With a Pre-existing Condition?
One of the parts of the health care reform law (the Patient Protection and Affordable Care Act of 2010) is a change to the way insurance companies are legally allowed to handle enrollees and potential enrollees who have pre-existing conditions. In most cases, health insurance companies will not be able to deny or cancel coverage for an enrollee on the basis of a pre-existing condition.

This may be a relief to you as someone with inflammatory bowel disease (IBD), as you may have encountered barriers to coverage in the past.

Answer: A pre-existing condition is any disease or condition that was diagnosed prior to a patient applying for a health insurance policy. In the past, a patient who had been diagnosed with a condition and who then experienced an interruption in health insurance coverage, or was changing insurance carriers, could be denied a policy because of their so-called pre-existing condition.

In the case of applying for health insurance through an employer, the pre-existing condition clause was limited to any condition that was treated during the prior six months. In addition, the pre-existing condition exclusion could not be applied as long as a patient had coverage for an entire year prior to switching jobs and did not experience a loss of coverage that lasted more than 63 days.

If an enrollee was granted a policy despite the pre-existing condition, the period during which an insurance company could refuse to cover any costs associated with the pre-existing condition was variable, but could be as long as 18 months.

What This Means for Those With IBD

For people with chronic conditions such as IBD, the ability for insurance companies to exclude coverage based on a pre-existing condition is a serious problem. IBD can not be cured, and because the disease stays with a patient throughout his or her lifetime, it requires periodic monitoring and continuous treatment.

The potential to be denied coverage is a constant concern.

Starting six months after March 23, 2010 -- the date the health care reform law took effect -- health insurance companies will be prohibited from denying coverage to children who have a pre-existing condition. In 2014, this will also apply to adults who have pre-existing conditions. In the meantime, starting 90 days after the bill took effect, federal funding is being made available for adults who have been uninsured for the prior six months and have pre-existing conditions. This funding will be available until 2013.

Also starting six months after enactment of the law, health insurance companies will not be able to cancel existing coverage due to a pre-existing condition. Coverage can only be canceled in the case of fraud, such as knowingly lying about the condition of your health. If coverage is going to be cancelled, the insurance company must inform the enrollee.

Sources:

Democratic Party Committee. "Summary of Health Care and Revenue Provisions." March 2010. 4 Apr 2010.

Democratic Party Committee. "Full Text of the Patient Protection and Affordable Care Act (P.L. 111-148)." 24 Dec 2009. 26 Feb 2013.

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