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Health Care Reform:

Health Insurance & Affordable Care Act

Getting Insurance When You Have a Health Problem

WebMD Medical Reference

For anyone living with a health condition, from asthma to diabetes to cancer, it’s a terrifying thought. What if I lose my health insurance? What would happen to my finances? My health? My family?

And if you have a pre-existing medical condition but don’t get insurance through your job, you already know how expensive health insurance can be. Many people go without health coverage because they simply can’t afford a policy. Others with health problems just get denied coverage altogether.

What is a pre-existing medical condition? The term can include just about any medical condition that you had before applying for insurance. Obviously, it includes serious problems like cancer, heart disease, and depression. But even acne, high cholesterol, or an old sports injury can be called a pre-existing condition. So can pregnancy, in some cases.

Why do insurance companies deny coverage or charge such high rates to people with pre-existing conditions? People with health problems cost insurance companies more than healthy people. So to save costs, many insurers use a practice called underwriting - they decide whether to cover someone based on his or her medical history.   

While health care reform promises to redress some of these problems, we don’t know yet if a bill will even pass. So if you’re trying to get insured with a pre-existing condition right now, what do you need to know?

Coping With a Pre-Existing Condition: Taking Action

If you have a medical problem and are losing your coverage, you must be anxious. But don’t give in to despair. You do have some options, imperfect though they may be. Here are some tips on what you can do.

  • Understand what kind of insurance you have. Most people get insurance through an employer. This kind of coverage, called group coverage, has special protections for people with pre-existing conditions. If you go from one job with group insurance to another with group insurance, you’re usually guaranteed coverage regardless of your medical history. People who don’t get coverage through work and have to buy individual insurance can face more serious problems if they have a pre-existing condition. 
  • Study the laws in your state. When it comes to insurance coverage, where you live can make all the difference. For instance, some states outlaw underwriting, some allow it. Underwriting is when an insurance company looks into your medical record to see what illnesses you’ve been treated for. Your first step is to find out how things work locally. Try healthinsuranceinfo.net, from Georgetown University’s Health Policy Institute, which has summaries of each state’s insurance laws.
  • Get help. Understanding insurance policies and state and federal law isn’t easy. So get some assistance from a professional, such as a case manager, financial assistance planner, or social worker. Many doctor’s offices and hospitals have a case manager on staff.
  • Move fast and stay focused. If you lose your group insurance through work, you need to stay on the ball. If you have to shift to individual coverage, a federal law called HIPPA guarantees that you can get insurance -- but not if you wait too long. If you go for 63 or more days without coverage, you’ll have what’s called a “significant gap in coverage.” And you will lose many of the protections you have. You may not be able to get any insurance after that point. So act quickly and don’t fall behind on your paperwork.
  • Extend your coverage with COBRA. If you’re losing your employer group coverage because of a layoff, a divorce, or other “qualifying event," you can usually keep the insurance for up to 18 months or longer using a federal law called COBRA. You’ll keep the same benefits, but you’ll probably pay much more than you paid as an employee.  Still, it may be the best option while you sort out what to do next. Keep in mind that COBRA isn’t automatic. You have to request it.
  • Find the insurer of last resort. Your state may have a designated insurer that gives anyone coverage, regardless of his or her medical condition or history. However, you need to apply within those 63 days of losing your previous coverage (including COBRA) to be eligible. The policy you get from the insurer of last resort may be expensive, but it’s probably better than nothing.
  • Look into a high-risk pool. Thirty-four states have insurance policies available to people who can’t get insurance because of health problems. You can get a list of states that have high-risk pools from the National Association of State Comprehensive Health Insurance Plan, or on their web site at www.naschip.org/states_pools.htm. You may be charged high rates, but if you have a serious health problem, it’s better than having no insurance.
  • Consider coverage through a membership organization. Some groups, such as professional organizations, unions, and chambers of commerce, offer insurance that’s cheaper than what you could find on the individual insurance market.
  • Start a business. Some people with pre-existing conditions use an interesting method to get insurance. They start up a business, hire themselves as the sole employee, and get group insurance. Using this “group of one” approach, you have the protections of any group insurance -- and can’t get turned down because of a pre-existing condition. You’re also protected by controls on how high the rates can be. However, it’s only an option in 13 states. Visit Georgetown University’s web site at www.healthinsuranceinfo.net/ for more information.
  • Look for government aid. Government programs like Medicaid and SCHIP (the State Children's Health Insurance Program) offer coverage to some low and moderate-income families. However, experts say that many people who are eligible don’t apply. Find out what’s available in your state and whether you might qualify. You can get information about government assistance programs from GovBenefits.gov.

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