Pre-existing condition

Source: Wikipedia, the free encyclopedia.
This article is about the term in health insurance. For medical use of the term, see Complication (medicine).

In the context of

Patient Protection and Affordable Care Act
.

According to the Kaiser Family Foundation, more than a quarter of adults below the age of 65 (approximately 52 million people) had pre-existing conditions in 2016.

Definitions

The University of Pittsburgh Medical Center defines a pre-existing condition as a "medical condition that occurred before a program of health benefits went into effect".[1] J. James Rohack, president of the American Medical Association, has stated on a Fox News Sunday interview that exclusions, based upon these conditions, function as a form of "rationing" of health care.[2]

Conditions can be broken down into two further categories, according to Lisa Smith of Investopedia:[3]

Most insurance companies use one of two definitions to identify such conditions. Under the "objective standard" definition, a pre-existing condition is any condition for which the patient has already received medical advice or treatment prior to enrollment in a new medical insurance plan. Under the broader, "prudent person" definition, a pre-existing condition is anything for which symptoms were present and a prudent person would have sought treatment.

Which definition may be used was sometimes regulated by state laws. Some states required insurance companies to use the objective standard, while others required the prudent person standard. 10 states did not specify either definition, 21 required the "prudent person" standard, and 18 required the "objective" standard.[4]

According to the Kaiser Family Foundation, more than a quarter of adults below the age of 65 (approximately 52 million people) had pre-existing conditions in 2016.[5]

Current U.S. federal regulation

Patient Protection and Affordable Care Act (Pub.L. 111–148) enacted March 23, 2010[6]

Former regulation

Regulation of pre-existing condition exclusions in individual (non-group) and small group (2 to 50 employees) health insurance plans in the

Kassebaum-Kennedy Act) of 1996 (HIPAA) extended some minimal limits on pre-existing condition exclusions for all group health insurance plans—including the self-insured large group health insurance plans that cover half of those with employer-provided health insurance but are exempt from state insurance regulation.[8][9][10][11][12][13]

Individual (non-group) health insurance plans[14][15]
Small group (2 to 50 employees) health insurance plans[16]
Large group (self-insured) health insurance plans
  • Maximum pre-existing condition exclusion period
    • 12 months: 50 states + DC
  • Maximum look-back period for pre-existing conditions
    • 6 months: 50 states + DC

Pre-existing condition exclusions were prohibited for HIPAA-eligible individuals (those with 18 months continuous coverage unbroken for no more than 63 days and coming from a group health insurance plan).

Individual (non-group) health insurance plans could exclude maternity coverage for a pre-existing condition of pregnancy.[2]

Group health insurance plans sponsored by employers with 15 or more employees were prohibited by the Pregnancy Discrimination Act of 1978 from excluding maternity coverage for a pre-existing condition of pregnancy; this prohibition was extended to all group health insurance plans by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).[2]

Practice and effect

Advocates against pre-existing condition rules argue that they cruelly deny people in need of treatment. State Farm spokeswoman K.C. Eynatten has said, "We realized our position was based on gut feelings, not hard numbers... we became aware that we were part of the reason a woman and her children might not leave an abuser. They were afraid they'd lose their insurance. And we wanted no part of that."[17] Jerry Flanagan, health-care policy director of Consumer Watchdog, has stated that "insurance companies want premiums without any risk" and go to extreme "lengths... to go to make a profit".[18] InsureMe, an insurance quote provider website, has argued that even though health insurance is basically to protect people from very high costs of health care, the commercial health insurance system is not playing fair and are always trying to avoid risk in order to boost their profits.[19]

Some practices by some health insurance companies, such as determining domestic violence to be an excludable pre-existing condition, have been called abuses by Maria Tchijov, a Service Employees International Union new media coordinator, and by an Office of Rural Health Policy report.[17][20][21]

The rationale behind pre-existing condition clauses, according to those who defend the policies, is that they reduce the cost of health insurance coverage for those who still receive it, thus giving more people an opportunity to afford insurance in the first place.

Republican from Wyoming, has voted to allow insurance companies to consider domestic violence as a pre-existing condition and supported his vote by saying that covering such people could raise insurance premiums to the point where it would preclude others from buying it. He has remarked that "If you have no insurance, it doesn't matter what services are mandated by the state".[17][23]

According to the California-based advocacy group

circus worker, and firefighter, and pregnancy and/or the intention to adopt.[18]

Commentary by lawmakers

According to a

non-Hodgkin's lymphoma as personal examples in the audience of those benefiting from changing pre-existing condition rules.[26]

Public opinion

A Time-Abt SRBI poll in late July 2009 found that a large majority of Americans (80%) favored a requirement that insurance companies insure people even if they have pre-existing conditions.[27]

In September 2009, the monthly Kaiser Health Tracking Poll report said:[28]

The public's most unanimous and bipartisan support is saved for a proposal to have the federal government require that health insurance companies cover anyone who applies, even if he/she has a pre-existing condition. Overall, eight in ten back the proposal, including 67 percent of Republicans, 80 percent of political independents and 88 percent of Democrats.

See also

References

  1. ^ "Billing terminology". Pittsburgh: University of Pittsburgh Medical Center (UPMC). 2010. Archived from the original on October 3, 2010. Retrieved January 16, 2010.
  2. ^
    PolitiFact.com
    . Retrieved January 17, 2010.
  3. ^ Smith, Lisa (February 16, 2009). "Health insurance: paying for pre-existing conditions". Investopedia. Retrieved January 17, 2010.
  4. ^ "Individual Market Portability Rules (Not Applicable to HIPAA Eligible Individuals)". July 21, 2014. Retrieved March 8, 2019.
  5. ^ Julie Rovner (October 11, 2018). "FACT CHECK: Who's Right About Protections For Pre-Existing Conditions?". NPR.org. Retrieved October 12, 2018.
  6. ^ "Side-by-side comparison of major health care reform proposals" (PDF). Washington, DC: Kaiser Family Foundation. March 22, 2010.
  7. ^ U.S. Department of Health and Human Services (June 28, 2010). "Patient Protection and Affordable Care Act; Requirements for Group Health Plans and Health Insurance Issuers Under the Patient Protection and Affordable Care Act Relating to Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections; Final Rule and Proposed Rule". Federal Register. 75 (123): 37187–37241. Retrieved July 26, 2010.
  8. PMID 8188152
    . Retrieved February 22, 2010.
  9. Government Printing Office
    . Retrieved February 22, 2010.
  10. PMID 9141331
    . Retrieved February 22, 2010.
  11. PMID 9637965
    . Retrieved February 22, 2010.
  12. PMID 10916957
    . Retrieved February 22, 2010.
  13. PMID 12674423
    . Retrieved February 22, 2010.
  14. Georgetown Health Policy Institute (January 2010). "Individual market portability rules (not applicable to HIPAA eligible individuals), January 2010". Washington, D.C.: Kaiser Family Foundation. Retrieved March 31, 2010. {{cite web}}: |author= has generic name (help
    )
  15. Georgetown Health Policy Institute (January 2010). "Non-group coverage rules for HIPAA eligible individuals, January 2010". Washington, D.C.: Kaiser Family Foundation. Retrieved March 31, 2010. {{cite web}}: |author= has generic name (help
    )
  16. Georgetown Health Policy Institute (January 2010). "Small group health insurance market pre-existing condition exclusion rules, January 2010". Washington, D.C.: Kaiser Family Foundation. Retrieved March 31, 2010. {{cite web}}: |author= has generic name (help
    )
  17. ^
    The Huffington Post
    . Retrieved September 19, 2009.
  18. ^ a b Hilzenrath, David S. (September 19, 2009). "Acne, pregnancy among disqualifying conditions". The Washington Post. p. A3. Retrieved January 16, 2010.
  19. ^ "Health insurance tricks to beware of". allinsuranceinfo.org. 2007. Retrieved January 20, 2010.
  20. ^ Johnson, Rhonda M. (August 30, 2000). "Rural health response to domestic violence: policy and practice issues". Washington, D.C.: Office of Rural Health Policy. Archived from the original on April 25, 2009. Retrieved September 15, 2009.
  21. ^ Tchijov, Maria (September 11, 2009). "Domestic violence is a 'pre-existing condition'?". SEIU Blog. Service Employees International Union. Archived from the original on September 16, 2009. Retrieved September 15, 2009.
  22. ^ a b Ricardo Alonso-Zaldivar; Trevor Tompson (November 17, 2009). "Americans fear health law's costs poll finds". San Francisco Chronicle. Retrieved January 16, 2010.[dead link]
  23. ^ Alonso-Zaldivar, Ricardo; Tompson, Trevor (November 17, 2009). "Americans fear health law's costs poll finds". San Francisco Chronicle. Associated Press). p. A118. Retrieved January 16, 2010.
  24. ^ Suderman, Peter (opinion blog) (September 23, 2010). "What the GOP's Pledge has in common with ObamaCare". Hit and Run. Reason. Retrieved September 23, 2010.
  25. ^ "Text of President Obama's health-care speech". March 3, 2010. Retrieved September 15, 2018.
  26. ^ Aizenman, N. C.; Kornblut, Anne E. (September 23, 2010). "Obama returns to stump for health care". The Washington Post.
  27. ^ "Time magazine/Abt SRBI — July 27–28, 2009 survey" (PDF). New York: SRBI. July 29, 2009. Archived from the original (PDF) on January 16, 2011. Retrieved September 21, 2009.
  28. ^ "Kaiser Health Tracking Poll—September 2009: Public opinion on health care issues" (PDF). Washington, D.C.: Kaiser Family Foundation. September 29, 2009. Retrieved January 16, 2010.

Further reading

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