Obamacare and You: If You Have a Pre-Existing Condition

If you or someone in your family has a pre-existing health condition – such as heart disease, asthma, or even a pregnancy – you will find it much easier to obtain coverage or change plans starting in 2014. Obamacare bars insurers from denying coverage to people with pre-existing conditions, or physical or mental illnesses or conditions that existed before coverage began. Insurers also can no longer refuse to pay for otherwise-covered medical care and services due to a pre-existing condition or charge you more because of a pre-existing condition in the family.

What’s Covered

If you don’t have insurance or want to change plans, you can shop for a new plan in the individual insurance market or on your state’s new health insurance marketplace (or exchange). These plans will cover doctor visits, hospitalization, prescription drugs and maternity care without any restrictions for pre-existing conditions.  They will cover preventive services like immunizations, screenings and contraception at no expense to you. You will not have to give your detailed health or medical history to apply.  The marketplaces will allow you to compare plans and prices. The open enrollment period for your state’s marketplace will run from Oct. 1 through March 31. Coverage begins on Jan. 1, 2014.

Types of Plans

Plans both in and out of the marketplace will come in four levels – bronze, silver, gold and platinum – that will vary in what they cover, what they charge in premiums and what deductibles and other out-of-pocket costs they require. But these plans cannot charge you more based on your medical history.  Insurers can only vary their premiums based on your age, the number of people in your family covered by the policy and whether you use tobacco.

Help with Premiums

If you buy a policy through your state’s marketplace, you may also be eligible for financial assistance to help cover the cost. In general, you may be eligible if you are a single person with an annual income in the range of $11,500 to $46,000, or if your household income is in the range of $19,500 to $78,000 for a family of three. The range will differ for families of different sizes. Use the Kaiser Family Foundation’s online calculator to get a rough estimate of the premiums and subsidies available to you. People with lower incomes who buy coverage through the marketplaces also may have their deductibles and other out-of-pocket costs reduced. If your income is lower, you may be eligible for coverage through Medicaid.

Other Options

Obamacare established a temporary program in 2010 to offer coverage to people with pre-existing conditions. If you have coverage through the Pre-existing Condition Insurance Plan in your state, you can remain enrolled through the end of January 2014, but are encouraged to get coverage in your marketplace as soon as possible.

If you currently have insurance you purchased on your own (and not through an employer), then the plan may be exempted from the law’s requirements about pre-existing conditions.  However, you can still drop that coverage and buy one under the new rules.

Questions

The federal government has set up a toll-free 24-hour hotline – 1-800-318-2596 – to answer consumers’ questions. To find out more about Obamacare visit www.healthcare.gov.

This fact sheet is also available in Spanish: en español.