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Your Pre-Existing Condition is Not a Barrier to Health Insurance and Other Obamacare Reminders

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Your Pre-Existing Condition is Not a Barrier to Health Insurance and Other Obamacare Reminders


Updated: March 22, 2017    Published: November 14, 2014

It used to be that health insurance companies could deny individual health insurance applicants coverage based on their health history. That means if you did not have access to employer-sponsored group health insurance and had a pre-existing condition such as diabetes, depression, asthma, or a history of irregular Pap smears, you might run into problems finding an individual health insurance policy. Those deemed uninsurable found themselves looking to government-created Pre-Existing Condition Insurance Plans, state high-risk pools or simply opted out of coverage all together.That all changed with health insurance plans effective Jan. 1, 2014, and later. The Affordable Care Act prohibits insurance companies from denying health insurance coverage to people with pre-existing conditions, refusing to pay for covered medical care related to such conditions, or charging those with pre-existing conditions more.

When you enroll in a health insurance plan for 2015, just as when you enrolled in 2014 coverage, remember this: Your pre-existing health conditions will not be a barrier to health insurance. This protection applies to catastrophic, bronze, silver, gold and platinum plans sold on and away from the state-based and federally facilitated health insurance exchanges.

As 2015 open enrollment gets underway, there are a number of Obamacare provisions, protections, and nuances to remember. The following apply to most health insurance plans that meet the health law’s minimum essential benefit requirements:

  1. Preventive care is included at no additional cost. Health insurance plans sold on and away from the exchange and grandfathered plans that were effective Sept. 23, 2010, and later include what is often referred to as free preventive care. That means specific preventive services and screenings are not subject to your plan’s deductible, copayments or coinsurance. Examples of such care include blood pressure screening, depression screening, obesity screening and counseling, and immunization vaccines. For a full list of preventive health services for adults, women and children, visit the Health Insurance Marketplace.
  2. Plans effective Jan. 1, 2014, and later include essential health benefits. All non-grandfathered, qualified health insurance plans sold on and away from the state-based and federally facilitated exchanges must include items and services in 10 categories of essential health benefits. The categories are the same everywhere; specific benefits vary by state and are based on a benchmark plan.

The 10 essential health benefits categories include:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Maternity and newborn care
  • Mental health and substance use disorder services, including behavioral health treatment
  • Prescription drugs
  • Rehabilitative and habilitate services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care
  1. There are no limits on essential health benefits. When it comes to medical care that falls within the 10 essential health benefits categories, annual and lifetime limits are a thing of the past. That means insurance companies cannot cap the dollar amount they spend on essential medical care. They may still limit annual and lifetime spending on medical care that does not fall into the essential realm. Note that grandfathered plans can still set annual limits; however, they are not permitted to set lifetime limits.
  1. If you get sick, your insurance company cant drop you. The Affordable Care Act prohibits insurance companies from canceling your coverage if you become ill.
  1. Children may remain on a parents health insurance plan through age 26. It used to be that young adults insured though their parents lost benefits once they reached a certain age or ceased to be a student. Young adults may now continue receiving benefits through their parents health insurance plan until they turn 26. This applies regardless of academic, marital or employment status. Even if an adult child lives outside his or her parents’ home or has access to employer-sponsored benefits, he or she may continue on a parent’s health insurance plan. This provision applies to individual health insurance plans effective Sept. 23, 2010, and later; as of Jan. 1, 2014, it applies to all group health insurance plans, even grandfathered ones.
  1. Financial assistance can help lower premiums and out-of-pocket costs. If you buy health insurance through your state’s state-based or federally facilitated exchange, you may be eligible for income-based financial assistance. Premium tax credits help reduce your monthly premium rate, and cost-sharing subsidies help reduce out-of-pocket spending related to your deductible, copayments and coinsurance. Use’s Obamacare Tax Credit Subsidy Calculator to estimate your premium tax credit.
  1. You are not required to buy from the Obamacare exchanges. When it comes to enrolling in ACA-compliant health insurance coverage, you have options. Qualified health insurance plans are available on the state-based and federally facilitated exchanges and also in the private marketplace where you can buy them directly from insurance companies, from agents and brokers, and through websites such as Be aware that if you are eligible for and want to receive subsidies, you need to buy health insurance from a state-based or federally facilitated exchange; subsidies are not available in the private marketplace.
  1. Needs change, and so can your coverage. You are not locked into your health insurance plan from year to year—even if your plan is set to automatically renew. Open enrollment is a time to comparison shop. Perhaps a bronze plan made sense in 2014, but your healthcare needs are changing and a silver plan feels right for 2015. Maybe the silver plan you have is not as good a fit as another silver plan available in your region.As you shop for 2015 health insurance coverage, think about your current medical conditions—or lack thereof—and consider the long-term. What care will you need in the year ahead? Maybe you expect to become pregnant, have surgery, begin counseling or need access to out-of-network care. Maybe your plan rate went up or the provider network or drug formulary changed. Consider what appointments, procedures, prescriptions and other medical costs you may need in the next calendar year. Factor in the unexpected, and take plan deductibles into account, too. The average deductible by metal level in 2014 ranged from $5,072 to $291 for an individual plan, and $10,327 to $578 for a family plan.[1] Will you be able to meet your plan deductible if necessary, or does it make more sense to pay a little more each month in premium and move to a plan with a lower deductible? Reevaluate and be sure the metal level you are in will continue to make the most financial sense.

    9. No health insurance coverage may cost you. The Affordable Care Act requires most Americans to have health insurance. If you go without minimum essential coverage and do not qualify for an exemption, you may face a tax penalty known as the individual shared responsibility payment. In 2015, the penalty will be the higher of the following2 percent of your annual household income—the maximum penalty is the national average bronze plan premium; or $325 per adult and $162.50 per child under 18—the maximum penalty is $975 per family.[2]

    10. 2015 open enrollment runs shorter than 2014. Open enrollment is half the amount of time it was during the last enrollment period. The 2015 open-enrollment season runs from Nov. 15, 2014, through Feb. 15, 2015. To ensure you have coverage effective Jan. 1, 2015, you must enroll by Dec 15, 2014. You may change your mind and switch plans anytime until Feb. 15, 2015.

    Use the plan finder at to see what health insurance plans are available in your region and estimate plan costs on and away from your state’s exchange. Need assistance? Call 877-275-0485 to speak with a licensed agent.



Centers for Medicare and Medicaid Services. The Center for Consumer Information and Insurance Oversight. “Additional Information on Proposed State Essential Health Benefits Benchmark Plans.”


The Henry J. Kaiser Family Foundation. “Obamacare and You: If You Have a Pre-Existing Condition.” Oct. 1, 2013.


Internal Revenue Service. “The Individual Shared Responsibility Payment — An Overview.” IRS Health Care Tax Tip 2014-04. March 20, 2014.


U.S. Department of Health and Human Services.


U.S. Department of Labor. “Young Adults and the Affordable Care Act: Protecting Young Adults and Elimination Burdens on Businesses and Families.”


[1] internal proprietary database information.

[2] “The Fee You Pay if You Don’t Have Health Coverage.”


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