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How are pre-existing conditions covered under ObamaCare?

Here's what you need to know...
  • Obamacare prevents insurers from using pre-existing conditions in insurance decisions
  • Obamacare permits age, location and smoking status as conditions for coverage
  • Smoker status can trigger additional charges and smoking cessation benefits
  • Insurers have obligations to provide essential benefits in geographic areas
  • Open enrollment is the period in which subscribers can get coverage without regard to health

Obamacare requires that insurers treat pre-existing conditions like any other illness or medical condition. They cannot base decisions for the price, coverage, and annual or lifetime limits on such conditions. Prevention is the key theory of the ACA; Obamacare requires universal coverage and acceptance by insurers. Obamacare providers offer, at no additional costs, essential health benefits. These include tests, screenings, physical examinations, diagnosis and treatment for addictions. Comparison shopping is more important when consumers must search a large number of plans and options to find the best match for a family or individual subscriber than when faced with only a few options. Compare health insurance rates now by using our FREE tool above!

Pre-existing Conditions

Pre-existing conditions were among the primary reasons that the nation moved to adopt health care reform. When left to its policies, the insurance industry used American’s health against them when seeking health insurance coverage.

Ordinary conditions like pregnancy, unavoidable statuses like gender, and child-bearing ages were used to deny or inflate the costs of insurance.

In 2008, the voters adopted policies favoring broad healthcare reform and universal coverage for those who needed health insurance. They wanted to end the practice of using pre-existing conditions to deny coverage to those who might need it most, namely, those with a need based on health status or illness.

Covering Sick People

Extending coverage to the uninsured Americans was a major goal of the Affordable Care Act. The costs to the nation of uninsured illness were huge and growing. Part of the problem is the rising costs of medical care where even simple procedures can cost tens of thousands when involving hospitalization and surgical procedures. Another issue was the gap between those who can afford insurance and those who cannot. Obamacare included vital provisions to expand Medicaid to include millions of adult who could not afford insurance. Covering the low-income portion of the population would also ease a growing burden of unpaid and uncollectible hospital bills. The weight of unpaid bills in some areas causes hospitals to curtail services or close.

Minimum Essential Coverages

The Affordable Care Act guarantees minimum essential coverage for everyone. Everyone eligible for Obamacare must get and keep minimum essential coverage or pay a fine based on a statutory scale. Qualified health plans sold through healthcare.gov or a state marketplace provides minimum essential coverage. Pre-existing conditions do not affect the essential coverages of Obamacare. Nor do they restrict the costs or costs assistance provisions that make insurance affordable such as tax credits for premiums.

Dropped Coverages

Not only did the insurance industry use pre-existing conditions to deny coverage; insurers were free to terminate coverages after discovering severe conditions. They routinely dropped coverages they did not wish to continue because of concerns about costs or resources.

In subscribers that had discovered conditions, the insurers would use pretexts to drop coverage.

This group included sick children with life-threatening conditions like cancer and birth defects. Obamacare does not permit insurers to take personal factors into account when making decisions on coverage except for age, smoking status, and location.

Open Enrollment Period

The open enrollment period for the calendar year 2016, began November 1, 2015. It runs through January 31, 2016. The government can extend the open enrollment for those who began but did not complete the registration process. The government can extend the open enrollment for reasons it finds necessary. Without a formal extension,  enrollment must be closed until the next open enrollment period unless an applicant qualifies for an exception. The exceptions to the open enrollment rule include the below described special enrollment periods for life events.

  • Birth of a child
  • Marriage or divorce
  • Moving to a different state
  • Loss of coverage as a dependent
  • Loss of coverage due to loss of employment

Open Enrollment Coverage Guarantee

Open enrollment guarantees that subscribers can get coverage without regard to pre-existing conditions. Obamacare does not permit exclusions based on factors other than age, location and smoking status. But these factors do not bar coverage.

Insurers can charge additional fees for self-identified smokers, and they can charge special premiums up to fifty percent higher than those who do not smoke.

The corollary benefit is that these subscribers get smoking cessation benefits including smoking cessation drugs at no out-of-pocket costs. Pregnant women get particular attention and benefits as theirs is a dual responsibility and additional risks to the unborn child.

The Risks of Tobacco Usage

It is hard to overestimate the harms and costs from tobacco usage in America. The Affordable Care Act made prevention and early detection a cornerstone of the approach to improving health in the US. The costs of tobacco usage in economic terms are staggering, and the costs in human terms describe one of the tragic situations of our time. Tobacco-related disease, illness, and deaths are a preventable set of harms and health consequences.

Essential Health Benefits

Essential health benefits are an important source of wellness and prevention under Obamacare. These no-cost services and benefits add value to every qualified health plan and to related state and federal services like Medicaid, CHIP, and Medicare. The below-listed items describe characteristics of essential health benefits.

  • No dollar limits on annual or lifetime basis
  • Ten categories of vital preventive services
  • Essential and not elective; they prevent and treat sickness.

Benefits Included in Medicare and Medicaid

Comparison shopping offers substantial advantages when assessing premiums, plans, and the available elective and essential benefits. There is no single or exact formula, and plans will vary substantially in the amounts of services they can offer. While the key prevention services have no additional costs, plans also vary widely to the types of facilities, therapies as well as to costs and copays for extended treatment.

Pre-Existing Conditions

Comparison shopping is particularly important for subscribers with a pre-existing health condition. According to government research, one in two persons has some pre-existing health condition. Eliminating it as a factor for coverage was a major reform of the Affordable Care Act. Applicants with pre-existing conditions can get tax-credit subsidies for monthly premiums if they earn 400 percent or less than the federal poverty guideline. So too are costs assistance for particular plans such as Silver Plans based on income rather than health.

The free or no costs prevention services go to those with pre-existing conditions in the same way as all other subscribers. Pre-existing conditions may require some increased level of services or some particular set of facilities and specialties. Comparison shopping can help find the best possible match. Enter your zip code in our FREE tool below to compare health insurance rates now!

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