Current federal requirements prohibit health insurance plans from denying coverage to individuals with pre-existing conditions like cancer.[1] These are one of several important patient protections that must be part of any health care system that works for cancer patients.
What is a Pre-existing Condition?
“Pre-existing condition” is a term used to describe any health problem that existed before the individual enrolled in a health plan and may make insuring that individual more expensive. These conditions could be something for which a person is currently being treated – like cancer – or a health problem the person was treated for in years past. Because there is no legal definition of pre-existing condition, health plans may decide which conditions count. Up to 133 million non-elderly Americans (51 percent) may have a pre-existing condition.[2]
What is a Pre-existing Condition Exclusion?
Prior to January 1, 2014, health insurance plans were allowed to:
- Refuse to cover an individual who had a pre-existing condition
- Charge the individual a higher premium based on the individual’s pre-existing condition – often making premiums unaffordable
- Provide insurance but refuse to cover expenses related to their pre-existing condition
Plans frequently used pre-existing condition exclusions, especially in the individual market. A survey conducted before these exclusions were prohibited found that 36 percent of those who tried to purchase health insurance directly from an insurance company in the individual insurance market were turned down, were charged more, or had a specific health problem excluded from their coverage.[3]
Why are the Protections Against Pre-Existing Exclusions Necessary for Cancer Patients?
Prior to prohibition of pre-existing condition exclusions, cancer patients and survivors were often denied or charged more for coverage because of their cancer diagnosis. According to American Cancer Society research, lack of access to health insurance coverage is associated with less access to health care and poorer outcomes for cancer patients.[4]
[1] This protection does not apply to individuals who are enrolled in a “grandfathered” health insurance plan.
[3] Doty MM, Collins SR, Nicholson JL et al. Failure to Protect: Why the Individual Insurance Market is not a Viable Option for Most US Families. The Commonwealth Fund, July 2009.
[4] Ward, E., Halpern, M., Schrag, N., Cokkinides, V., DeSantis, C., Bandi, P., Siegel, R., Stewart, A. and Jemal, A. (2008), Association of Insurance with Cancer Care Utilization and Outcomes. CA: A Cancer Journal for Clinicians, 58: 9–31. doi:10.3322/CA.2007.0011.
