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Health Reform and Pre-Existing Conditions: Getting Insurance

WebMD explains how health reform will affect those with pre-existing conditions and how they can get insurance.

Under the Affordable Care Act, people with pre-existing health conditions cannot be denied health insurance as of 2014, when the law takes full effect.

WebMD readers submitted a number of questions about this aspect of the law. Here are answers.

Q: Will there be a limit as to how high a premium insurance companies can charge if you have a pre-existing condition?

A: Yes. As of 2014, insurers cannot charge consumers different rates for health insurance because of health status or gender.

You can be charged more for your age, however, with older people paying a higher premium than young people. But that increased charge is capped at no more than three times the standard rate.

Q: I am a 44-year-old with Stage IV Lung Cancer. I would like to have comfort in knowing that I don't have to worry about having a restriction on my lifetime benefit. Right now there is none, due to Health Care Reform, but what if they decide to get rid of it?

A: That’s not likely to happen.

For health plans beginning after Sept. 23, 2010, insurance companies can no longer impose lifetime limits on benefits. That’s a big deal for people with serious illnesses, such as lung cancer, or other chronic conditions requiring ongoing and/or very expensive care.

Since the Affordable Care Act was passed in March 2010, many threats to repeal the law have been made. In fact, in January 2011, the House of Representatives did vote to repeal the Affordable Care Act, a measure that was rejected by the Senate. That means that the benefits gained thus far under the law are still in place.

Although lawmakers can hold up money to fund aspects of the law that have yet to be implemented, repealing the law as a whole or even specific consumer protections (such as no lifetime limits for care) is not likely.

Q: Will the definition of pre-existing conditions change by 2014, when the Affordable Care Act goes into full effect?

A: A pre-existing condition is generally considered an illness or disability a person has prior to applying for health insurance coverage. Currently, the definition varies among states and even by insurance plans.

However, once the law takes full effect in 2014, that definition will lose its importance. Under the law, no one can be denied health care insurance for any reason, including an existing medical condition.

Q: What if I'm healthy but risky? If you're fine now but you have certain risks you can't change, can you be denied coverage?

A: As it stands now, if you apply for insurance on the private market (as opposed to getting it through your job), insurance companies will look into your medical history and can deny you coverage based on what they find, including perceived health risks.

As mentioned above, effective in 2014, insurers will no longer be able to deny anyone on the basis of their medical history.

Q: Exactly what can insurance companies deny now that we have the new laws in place?

A: Benefit plans sold through health exchanges will be required to provide certain essential services, including inpatient and outpatient care, wellness and prevention services, maternity and newborn care, among others. You can find a more complete listing of essential services under the law at Healthcare.gov.

Beyond complying with this requirement, however, each health insurer will be allowed to design benefit plans as it chooses (complying with state and federal law, of course). For that reason, it is essential that you understand the terms of your individual plan and follow the rules set forth in your policy to ensure that your care is paid for.

Q: Some insurance companies have discontinued sales of some policies, such as those for juveniles with pre-existing conditions. Have the insurers found a loophole in the law?

A: As of September 2010, a provision of the health reform law that prohibited insurance companies from excluding children younger than 19 with pre-existing health conditions went into effect. In response, many insurance companies dropped out of the child-only market instead of taking on the cost of these potentially expensive policies. In this case, insurers did, in fact, find a loophole.

A number of states, however, have taken legislative or regulatory action to keep insurers in the child-only insurance market. In California, one of a handful of states to take such action, insurers who refused to sell child-only policies would be forbidden to sell any policies in the lucrative private market for five years. As a result, all insurers jumped back into the child-only market effective Jan. 1, 2011.

“That’s the point of having aggressive regulation at the state and federal level,” says Anthony Wright, executive director of the health care advocacy organization, Health Access California. Legislators will be in the position of identifying and plugging loop holes in an effort to continually improve upon the law.

“There needs to be vigilance because insurers have shown they may need to be dragged kicking and screaming into a newly reformed world,” Wright says.

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