Pre-Existing Conditions Program

Reviewed by: HU Medical Review Board | Last reviewed: March 2011. | Last updated: January 2022

Starting in 2014 insurance companies will no longer be permitted to deny coverage to adults with pre-existing conditions or charge them higher premiums. Until then people living with a health condition they were diagnosed with before enrolling in a health insurance plan (like migraines) are left out in the cold. To help provide coverage for people caught in that situation the 2010 Affordable Care Act offers a temporary Pre-Existing Condition Insurance Coverage Program for people who cannot get insurance coverage and don’t have coverage through an employer or spouse.

Depending on which state you live in you will be covered under a state-run or federal-run program. Some states will run their own programs, while others will allow the federal government to run the program for them. For instance, in my home state of Kansas the state is running its own program through the Kansas Health Insurance Association (KHIA State Pool). The only requirements for eligibility are (1) you’re a legal US resident, (2) you’ve been without insurance coverage for at least six months and (3) you have a pre-existing condition. To satisfy the third requirement you can either have your doctor certify that you have been diagnosed with one of a number of specific conditions or submit a denial letter from an insurance company. Upon their receipt of your documentation you are immediately covered. It’s really quite straight forward.

Plan members pay a monthly premium and have access to a full range of medical providers and services. The federal law requires their premiums to be the same as those paid by other people buying health insurance through regular insurance programs.

Unfortunately, as you hopefully just noticed, to be eligible to apply you must have been without health insurance coverage for six months. I find this requirement extremely frustrating. This kind of delay leads to catastrophic consequences for people’s health and financial stability. If you have a pre-existing condition you most likely need treatment for that condition. After all, that’s why insurance companies have refused to cover you: you’ll be too expensive. A program that’s supposed to fill the gap while we wait for the law prohibiting insurance companies from discriminating on the basis of pre-existing conditions to take effect leaves yet another gap for people who already have compromised health. A year for your condition to go largely untreated. This not only harms the individual, it drives up the cost of health care for everyone by leaving treatable conditions undertreated, creating a need for more expensive interventions down the line. The program is certainly better than nothing and I get that they are discouraging people from dropping existing coverage to enroll in these programs, but I wish its requirements were more reflective of the needs of people living with pre-existing health conditions. For us six months can be a really long time.

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