Private Health Insurance for Pre-Existing Conditions

Private health insurance for pre-existing conditions is regulated the same for someone without a long medical past. Private health insurance companies are required to comply with Affordable Care Act guidelines, which means they cannot deny or over-price coverage because of a pre-existing condition. If you are enrolling in a health insurance plan with one of these conditions, don’t stress about being targeted with high premiums or deductibles.

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Rachael Brennan has been working in the insurance industry since 2006 when she began working as a licensed insurance representative for 21st Century Insurance, during which time she earned her Property and Casualty license in all 50 states. After several years she expanded her insurance expertise, earning her license in Health and AD&D insurance as well. She has worked for small health in...

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Benjamin Carr was a licensed insurance agent in Georgia and has two years' experience in life, health, property and casualty coverage. He has worked with State Farm and other risk management firms. He is also a strategic writer and editor with a background in branding, marketing, and quality assurance. He has been in military newsrooms — literally on the frontline of journalism.

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Reviewed by Benji Carr
Former Licensed Life Insurance Agent Benji Carr

UPDATED: Feb 10, 2022

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Quick Facts

  • You cannot be denied health insurance because of a pre-existing condition
  • Private health insurance plans can’t be increased based solely on your pre-existing condition
  • Medicaid and other federal programs cannot deny you coverage either

Understandably, applying for private health insurance with pre-existing conditions could seem intimidating, but it shouldn’t. Since 2014, all insurers on the Marketplace have been legally required to cover treatment for pre-existing medical conditions. Now, some companies are tailored to your needs.

Keep reading to learn more about pre-existing conditions, how they are diagnosed, and which private health insurance plans are right for you. There may be some difficulties when it comes to navigating certain processes with a pre-existing condition, but finding affordable health insurance is not one of them.

Note: You also can’t be denied term life insurance due to a pre-existing condition, though you may be required to get a medical exam.

If you’re ready to speak with someone in your area about rates for private health insurance for pre-existing conditions, use our free tool. Enter your ZIP code to start comparing private health insurance quotes today. 

What is a pre-existing condition?

Before we dive into this private health insurance pre-existing conditions tips and tricks guide, let’s talk about the phrase “pre-existing condition.” 

As defined in the Affordable Care Act (ACA), a pre-existing condition is a health problem that started before the date of a new health insurance policy.

It’s a term used in the healthcare industry that once meant “exclusion.” In 2014, those with ailments and diagnoses may have been forced to enroll in the federal Pre-existing Condition Insurance Plan (PCIP). Since the full rollout of the ACA, the PCIP has been dissolved, and private insurers are prohibited from refusing applicants coverage for their pre-existing conditions.

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How are pre-existing conditions determined?

It is a condition that you either report or your health insurance provider sees in your medical record during the application process. Medical records are not always required since you cannot be denied due to a pre-existing condition.

What are some examples of pre-existing health conditions?

Pregnancy, for example, could be a temporary form of a pre-existing condition. Other common conditions are:

  • Arthritis
  • Asthma
  • High cholesterol
  • Hypertension
  • Obesity
  • Cancer
  • Alcohol and drug abuse
  • Kidney disease
  • Mental disorders
  • Lupus

Sometimes, conditions that are as far back as 10 years on your medical record could qualify as “pre-existing.”

Though private health insurance cannot be impacted by your health, companies sometimes can wiggle around the rules. Keep reading to learn more about the private health insurance definition of bending — not breaking — the rules.

Can I get any private health insurance with a pre-existing condition?

Let’s back up. There have been a few acronyms introduced that are important. ACA, or the Affordable Care Act, was a healthcare overhaul enacted into Congress on March 23, 2010, with the goal of ensuring anyone could buy health insurance.

As a result, health insurance companies on the Marketplace could no longer avoid providing coverage to those with pre-existing conditions.

Between 2010 and 2014, anyone with a pre-existing condition could get health insurance through the Pre-existing Condition Insurance Plan (PCIP) until the end of that four-year deadline.

Now, many years later, no person may be denied health insurance coverage solely based on their pre-existing condition. The act also eliminated waiting periods that required those with pre-existing conditions were to remain on employer-sponsored plans.

However, some loopholes may impact acquiring coverage. Keep reading to learn more.

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Can I be denied health insurance if I have a pre-existing condition?

No. No one can be denied a health insurance policy that the ACA has regulated. There are specific policies and circumstances where an insurer could deny coverage to someone with a pre-existing condition.

Grandfathered plans, health insurance policies that the ACA doesn’t regulate, and group plans are the three coverage types that may still deny you if you have a pre-existing condition.

Suppose you’re offered a private health insurance quote reflecting your pre-existing condition. In that case, you may be looking at a short-term medical plan, often referred to as temporary health insurance. This type of plan usually ends within a year and provides coverage for certain services, such as routine office visits, preventive care, and prescription drugs. The other non-regulated health plan is a fixed indemnity plan. 

If you don’t need to buy private health insurance, you may have been assessed based on your medical history. Any policy that was purchased before March 23, 2010, is grandfathered in and does not need to abide by the pre-existing condition rule of the ACA.

The final category that is allowed to prohibit coverage is insurers in the large group market. This means any group — generally an employer of some kind — can use the collective medical history to determine the price of coverage. However, it’s more common for large groups to contract with an insurance company for individual health coverage.

Keep reading to learn more about which private health insurance companies are the most affordable and accessible to those with medical conditions. 

What are the best private health insurance companies if you have a pre-existing condition?

The fear of having a pre-existing condition and applying for health insurance is more than likely associated with cost. If you have a condition that requires regular visits to the doctor or expensive medicine, you may want to look for an insurance company that offers more than just the basic policy. 

Some companies offer plans with low deductibles without gouging for premiums. Others offer catastrophic coverage for when your primary plan isn’t covering your medical bills. 

See the table below for some terms to be aware of as insurance providers rank your risk: 

ClassPersonal HealthFamily History
Preferred Nonsmokers in great health with a minor conditionMinor health conditions in family history
Preferred SelectNonsmokers in great healthNo family history of health conditions
Preferred SmokerSmokers in great healthNo family history of medical conditions
StandardNonsmokers with average healthSome medical problems in family history
Standard PlusNonsmokers in good health with a few minor health conditionsMinor conditions in family history
Standard SmokerSmokers in good healthSome medical conditions in family history
Table RatingPoor health Medical conditions in family history
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Remember that you are not required to purchase private health insurance with a pre-existing condition. You can also receive Medicare benefits. See which one is right for you

Private Health Insurance for Pre-Existing Conditions: The Bottom Line

Now that you know the rules, applying for private health insurance with pre-existing conditions does not have to be intimidating. All insurers that the ACA regulates are required to provide affordable health insurance to everyone — even those with pre-existing conditions. As we learned, some companies may better serve your medical needs than others.

Now, you’re ready to speak with someone in your area about quotes for private health insurance with pre-existing conditions. Use our free tool to start comparing private health insurance quotes. Enter your ZIP code today.

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