The Affordable Care Act’s pre-existing condition exclusion provision prohibits health insurers from denying coverage to individuals because of a pre-existing health condition. This provision is also referred to as "guaranteed-issue" because everyone - regardless of health conditions - is guaranteed to be issued health coverage.
Under the Affordable Care Act (ACA), pre-existing condition exclusions were eliminated for children (under age 19) beginning in September 2010. This provision of the ACA was expanded in 2014 to all enrollees.
Here are five frequently asked questions (FAQs) about the pre-existing condition exclusion.
(1) What is the pre-existing condition exclusion?
A pre-existing condition exclusion means health insurers and employers cannot limit, exclude, or deny coverage based on the fact that a health condition was present before the effective date of coverage (or if coverage is denied, the date of the denial). The provision applies to all group health plans and non-grandfathered individual health insurance plans.
(2) When does the pre-existing condition exclusion provision go into effect?
The pre-existing condition exclusion provision is effective as of the first plan year on or after January 1, 2014.
(3) Are grandfathered plans exempt from the pre-existing condition exclusion provision of ACA?
Grandfathered individual plans are exempt from this provision of ACA. However, grandfathered group health plans are not exempt. Read more about grandfathered health plans here.
(4) Since pre-existing condition exclusions will no longer be permitted, will Certificates of Creditable Coverage (COCC) be sent in 2014?
Yes, insurers are still required to send COCC letters in 2014 under certain situations, such as when an individual loses coverage under a plan.
(5) What's happening to the Pre-existing Condition Insurance Plan (PCIP) programs?
The ACA established a temporary federal high-risk pool called the Pre-existing Condition Insurance Plan (PCIP) as a temporary insurance option for individuals who had been denied coverage because of a pre-existing condition. This program is still in effect for those who signed up before new applications were suspended on March 2, 2013. PCIP coverage is extended through March 31, 2014.
What questions do you have about the pre-existing condition exclusion provision (aka "guaranteed-issue")?