How to Get Covered by Insurance Even if You Have a Preexisting Condition

People undergoing treatment for chronic conditions—like depression, diabetes, high blood pressure, or cancer—need to be careful to avoid triggering what’s known as a "preexisting condition" exclusion. Once you trigger this clause, most carriers will try to deny paying any claims for that condition for a period of time. Karen Pollitz, project director at the Health Policy Institute at Georgetown University, explains how to keep yourself covered.

Q: What’s the best way to maintain my health-care coverage if I have a chronic condition?

A: The first thing I recommend is to see if there is any way you can qualify for job-based coverage. Are you in a job that offers benefits that you hadn’t signed up for, or do you have a spouse with a job that has benefits?

The reason is that you have the most legal protection in job-based health plans. Under the Health Insurance Portability and Accountability Act (HIPAA), if the coverage is offered, the employer can’t say, "I’m not going to let you into my health plan because you have breast cancer"—or any other health issue. They must offer you the same benefits and they must kick in the same percentage of premium as they would for anyone else.

Bottom line: Job-based health plans also tend to be the most affordable, because employers pay, on average, about 75% to 85% of the premium for you.

Q: So my chronic health condition will not be a problem if I have coverage through an employer?

A: Although the employer cannot discriminate against you, the health plan can still deny coverage of preexisting conditions for new employees for a period of 6 to 12 months. However, if you had any kind of prior health insurance—and no gap in coverage—the amount of time you had it can be credited against the exclusion period of your new plan.

Bottom line: Under HIPAA, a gap in coverage is defined as 63 days or more (although in some states it may be longer under state law). Once you hit 63 days without insurance, treatment for your condition can be denied for 12 months when you enroll in a new health plan. The maximum legal exclusion period for any group health plan is 12 months (or 18 months if you join the health plan late). However, if you have an individual health plan, the laws vary a lot by state, and you should contact your state insurance department for details.