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California Health Insurance and Pre-Existing Conditions

Pre-existing conditions and California health insurance


There's a lot of talk now on Pre-existing conditions coming back with the new health care law.

Let's look at what is being discussed and understand that everything is still in flux.

Here's the broad stroke of what is being proposed (but not finalized):

If a person goes uninsured for a period time, there may be an increase of premium for 30% applied to their premium.

There's talk about high risk pools for people that won't qualify outside of open enrollment.

Here's the deal...

We don't see any change in the Guaranteed Issue coverage for pre-existing conditions with the discussed changes ESPECIALLY if you stay insured.  We'll update as we get clarity.

Medical Underwriting is No Longer Required

Almost everyone has one....that dreaded term in California health insurance called pre-existing conditions. 

Fortunately, health is no longer a factor in qualifying for health insurance since Jan 1st, 2014. 

 There are no health history questions on the application either through Covered California or off-Exchange directly with the carrier. 

Instead of medical underwriting, there are now open enrollment windows during which we need to apply. 

This period is generally Nov 15th-Jan 31st (but check with us since it can change). 

Outside of Open Enrollment, there are certain triggers that allow a person to enroll such as moving, losing other coverage, changes in income, etc. 

More information on those triggers if you missed Open Enrollment.

Quote the Guaranteed Issue plans available here:

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Definition of pre-existing condition for California health

pre-existing conditionsFirst, what is a pre-existing condition?

The hard definition is a medical condition, illness, injury, or medical services which has occurred in the last 6 months.

The 6 months is important for one effect of pre-existing conditions (waiting periods) but does not hold for medical underwriting which can look at a longer duration depending on the severity of the issue.

Let's break pre-ex affects into two categories.

Waiting periods in California for pre-existing conditions

Now, there used to be another consideration with pre-existing conditions called waiting periods.

Generally, if you had a pre-existing condition when approved and you did not have qualified coverage in the past 6 months without a recent lapse of coverage of 62 days, the California health carrier would not pay out for treatment related to that condition for 6 months.

Waiting periods have also gone away since Jan 1st 2014 with the ACA law

Can pre-existing conditions be excluded for California health insurance?

California was always somewhat unique among the States in that the carriers are not allowed to exclude pre-existing conditions as they will do in other States. 

The ACA law has brought this to all the States now but again, it was not an issue in California.

Can a person be approved but have rates go up based on pre-existing conditions?

No.  Rates are standardized by the ACA law and are only affected by age, zip code, and plan choice. 

Income also figures in now significantly since tax credits are available based on income which can significantly affect the pricing and benefits available. 

Related Articles:
Open Enrollment and Covered California
Tax credits or subsidies through Covered California

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