Understanding Pre-Existing Medical Conditions: Impact & Coverage

Pre-existing medical conditions are diseases that are present before a patient receives current or future medical treatment. Many people think of health insurance when they hear about pre-existing conditions. However, pre-existing conditions can also impact patient care and reimbursement.

Examples

• Examples of common pre-existing conditions include pregnancy, obesity, arthritis and depression.

Medical Care

• Pre-existing conditions are taken into consideration when a doctor treats a patient for current conditions. For example, a patient with pre-existing high blood pressure would not be treated for a current condition with a drug that has a side effect of increasing blood pressure.

Reimbursement

• In some cases, pre-existing conditions may impact how a health care provider is reimbursed. Pre-existing conditions combined with a patient's current condition utilize more resources in treating the patient. Therefore, reimbursement amounts may be higher.

Insurance

• Previously, when a patient switched jobs and was offered a new health insurance plan, the new company was not required to insure the treatment of pre-existing conditions. This changed under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

HIPAA

• Patients previously insured under group plans may have the ability to receive coverage for pre-existing conditions under HIPAA. For example, conditions can only be excluded from coverage if diagnosis or treatment was made within six months prior to new enrollment. Additionally, HIPAA does not allow exclusions for conditions like pregnancy or genetic diseases.