Why do some insurance policies still use pre-existing conditions?

By Larry Alkire, Senior Vice President, Chief Marketing Officer, American Fidelity Assurance Company

When Congress passed the Affordable Care Act (also known as Obamacare), the term—”pre-existing conditions”—became a household word. The ACA prevented health insurance carriers from denying you coverage, charging you more money, or refusing to pay for essential health benefits for any condition you had before your insurance coverage started. It also prohibited health insurers from denying you coverage or raising your rates once you’re enrolled in a plan based only on the health claims you filed.

No doubt, the ACA was a game changer for health care coverage. The legislated ban on healthcare “pre-ex” limitations opened the possibility for many people to get immediate coverage that they previously could not.

Health insurance, particularly employer-provided healthcare plans, typically have a larger enrollment of healthy people when compared to other employee-paid insurance. This is because employer-provided health insurance covers most employees and the company pays a portion of the insurance premiums. With high participation levels, the likelihood of anti-selection (a higher concentration of unhealthy participants) is reduced significantly—especially when compared to supplemental and voluntary insurance products.

Although pre-existing condition limitations are considered to be a negative for consumers, employee-paid supplemental coverage has a unique structure that features complex consumer/carrier tradeoffs.

Voluntary benefits that are commonly purchased by employees at work can include disability, life, long-term care, critical illness, and cancer coverage. Depending upon the type of insurance you select, the plan may ask no health questions when you apply (guarantee issue—typically for new hires and during open enrollment periods), limited health questions (sometimes referred to as simplified or express issue coverage), or a lot of health questions (full underwriting sometimes accompanied with verification).

The trend over the last few years is for applications for voluntary insurance to require less underwriting. However, with less underwriting comes a greater need for carriers to use pre-existing condition limitations. But is that a bad thing?

Actually, there’s a benefit to most consumers when insurers use pre-existing condition limitations. The “pre-ex” limitation allows carriers, particularly group insurance carriers, to bring insurance plans to many employers and their employees. It allows people to obtain coverage (on a guaranteed issue basis in many cases) by limiting insurance during the first year or two after they initially make the purchase to conditions that didn’t exist at the time of application, or people weren’t actively being treated for. This is usually true, even if you have serious pre-existing conditions.

Consider the alternative. Not having a “pre-ex” limitation could force insurance carriers to screen out people at a much more intensive level. Having less people in the plan makes the premiums more expensive.

Consider the following points when you’re thinking about “pre-ex:”

Applicants usually know they have a condition that an insurance carrier would say makes them “uninsurable.”
It is best to identify whether or not you have a pre-existing condition before you apply for insurance coverage. If you have a pre-ex condition, open enrollment is a golden opportunity to obtain coverage. You will not be covered for your pre-existing condition for the first year or two, but you will be for anything else that happens to you. (Keep in mind that you could be covered for your pre-ex condition one you are treatment-free for that condition for one to two years.)
New applicants should always understand how the coverage works—and ask questions—before they buy it, and review their policy certificate again when they receive it.

The bottom line is that a pre-existing condition limitation often allows consumers with health issues to still buy supplemental and voluntary insurance. The limitation only applies to your specific condition and not all other conditions or injuries. And an open-enrollment-eligible plan is a great opportunity for an employee to take care of the needs they and their families have—even if they have serious health issues.