Health Insurance for Children With Pre-Existing Conditions

The Patient Protection and Affordable Care Act of 2010 significantly limited the exclusions health insurance companies can impose on children under the age of 19. The new law states that health plans that cover children can no longer exclude, limit or deny coverage to children under 19 because of a pre-existing condition. A pre-existing condition is a condition, illness or disability that has been diagnosed or treated before applying for health insurance.

Effective Dates

• According to the United States Department of Health and Human Services, the pre-existing condition rule applies to all new health plans issued after March 23, 2010, and will be effective when the new plan year begins on or after September 23, 2010. This applies to both employer-sponsored health plans as well as individual plans, and protects children with health problems and disabilities that were discovered or treated before you applied for health insurance coverage. The new rule will not apply to individual health policies that were purchased on or before March 23, 2010 until 2014. Federal law prohibits Medicaid and the Children's Health Insurance Plan (CHIP) to deny coverage for children based on their health status.

Provider Requirements

• Although the law prevents health plans for children from denying or limiting coverage, insurers are not required to provide coverage for children. If allowed under state law, issuers of individual and family policies may restrict the enrollment of children under 19 to specific enrollment periods. Employer-sponsored health plans that offer coverage to employee dependents must follow the new law regarding coverage for pre-existing conditions and cannot exclude an employee based on his claims history. They are, however, permitted to discontinue offering coverage for family members, provided the decision applies to all employees.

Open Enrollment

• Insurance providers are prohibited from discriminating against children under 19 with pre-existing conditions by limiting them to a specific period of open enrollment if enrollment of children without pre-existing conditions is allowed at different times. This applies to child-only health insurance as well as family plans.

Cancellation and Non-Renewal

• Under state and federal laws in effect prior to the Affordable Care Act, all individual policies are guaranteed renewable. The act prohibits insurers from canceling coverage for reasons other than fraud or intentional misrepresentation. It guarantees children under age 19 with child-only insurance can continue coverage as long as the insurance company continues to provide that type of health insurance.

Loss of Group Coverage

• If a child has been insured for 18 consecutive months or continuously since a date within 30 days of her birth, and loses group coverage, she is eligible for guaranteed-individual health-insurance coverage under the Health Insurance Portability and Accountability Act (HIPAA). The child must be allowed to apply for HIPAA coverage within 63 days of losing group health insurance. The birth of a new child and adoption of a child are HIPAA qualifying events, as well.