Individual Insurance: What Is Considered Preexisting Conditions?

Health insurance is often a necessity for receiving quality medical care. Many people are able to secure health insurance through either a spouse, parent or employer, however, there are a growing number of people who are unable to do so. Those individuals with pre-existing medical conditions are increasingly unable to obtain coverage through private health insurers and as a result may only be able to obtain insurance at a prohibitively high cost or through alternative methods.

Pre-existing Condition

• Health insurance companies classify a pre-existing condition as any medical condition that existed before someone applied for or enrolled in a new health insurance policy. While this includes serious illnesses like cancer and heart disease, it can also include minor conditions like hay fever, asthma or sports injuries. If an insurance company determines that you have a pre-existing condition, you may receive incomplete coverage, coverage at a higher-than-average premium or be denied coverage altogether.

High-Risk Pools

• If you have been denied health insurance by a private insurer you may be able to receive coverage by enrolling in a high-risk pool. This type of health insurance program is usually privately self-funded and state-organized. State-run plans are usually less stringent than private plans and often provide comprehensive health plans that provide many if not all of the same benefits as standard health insurance programs. States usually cap premiums at 125 to 150 percent of the state market rate; however, depending on your age, health and the state you live in, this can still be considerably higher than than a private insurance plan. Thirty-five state currently offer high-risk pools.

PCIP

• In July of 2010, the federal government passed legislation for the new Health Care Bill. Part of this bill addressed the need for more pre-existing insurance plans. There are 37 states offering state-run, federally funded plans; the rest rely on the federal Department of Health and Human Services to administer plans. The new plans, referred to as PCIPs, or pre-existing condition insurance plans, offer plan premiums that are much lower than those offered by most high-risk pools or private insurance companies.

Eligibility

• To qualify for a PCIP, an applicant must have been uninsured for at least six months before the application date, and therefore not enrolled in a high-risk pool or private insurance plan during this time. Likewise, those who are unemployed and and receiving Cobra health insurance are also ineligible. In addition, potential enrollees must provide either a letter of denial or similar proof stating that they have been denied health coverage due to a pre-existing condition. To find out if your state offers a PCIP plan, you can visit the PCIP website.