Preexisting conditions
Health insurance companies cannot deny you coverage or charge you more because of an existing health condition or disability. When deciding how much to charge you, companies can only use your age, where you live, whether you smoke or use tobacco, and whether the coverage you're buying is for an individual or a family.
Children included
Children may stay on their parents' plans until age 26. They don't have to live at home, be enrolled in school, or be claimed as a dependent on their parents’ tax return. Children with disabilities may continue to get coverage after age 26. And Texas law requires insurers to provide coverage for dependent grandchildren up to age 25.
How to appeal
Most plans have a process to appeal if a claim is denied. If you appealed with your health plan, and you're not satisfied, you may be able to request an external review by an independent group. To learn more about that process, visit the Federal External Review Process website.
No dollar limits
Insurance companies cannot put dollar limits on the amount they will pay for the covered health care you receive in a year or over your lifetime.
Filing a complaint
TDI regulates individual and some employer health insurance and can help you with complaints about those plans. If your health plan ID card has “TDI” or “DOI” on it (see examples), you can file a complaint with us. Learn more about how to file a complaint or call 800-252-3439 for help.
If you want to find more information about other types of health coverage visit Texas Health Options online.
As attention focuses, again, on the possibility the Affordable Care Act (ACA) could be overturned, millions of people with pre-existing conditions have reason to be concerned. Among many other provisions, the ACA prohibited private health insurance discrimination based on health status – insurers are prohibited from turning people down, charging them more, or amending coverage to exclude their pre-existing conditions.
What are pre-existing conditions and who has them? As defined most simply, a pre-existing condition is any health condition that a person has prior to enrolling in health coverage. A pre-existing condition could be known to the person – for example, if she knows she is pregnant already. People might also apply for coverage when they unknowingly have an undiagnosed condition – for example, tumor cells might be growing within but won’t be diagnosed until months or years later. A pre-existing condition might be mild – for example, seasonal allergies or acne treated with simple medications. Or it could be more serious or require more costly treatment – such as diabetes, heart disease, or cancer.
Declinable Pre-existing Conditions
KFF has estimated that in 2018 about 54 million non-elderly adults in the U.S. (27%) had “declinable” pre-existing conditions that would have made them “uninsurable” in the pre-ACA individual health insurance market. Declinable conditions were identified through an analysis of health insurer underwriting manuals. Insurers maintained lists of health conditions for which applicants would routinely be denied coverage. Declinable conditions included AIDS/HIV, congestive heart failure, diabetes, epilepsy, severe obesity, pregnancy, and severe mental disorders. Obviously, not all of these 54 million adults buy individual health insurance coverage now. But the individual market is where people go when they are between jobs that offer health benefits and ineligible for public plan coverage such as Medicare or Medicaid. If it would revert to medically underwritten coverage – as it was prior to the ACA in most states – these 54 million adults could be uninsurable if they were laid off from their job and lost their job-based health benefits.
Other Types of Pre-existing Conditions
Other estimates put the number of non-elderly adults with pre-existing conditions as high as 102 million, 122 million, or 133 million. In addition to declinable conditions, these estimates took into account conditions that would not necessarily get a person denied when applying for individual health insurance then, but that could trigger other adverse actions. Hypertension (high blood pressure) is an example of one such common pre-existing condition affecting more than 33 million adults under 65. A KFF study of medical underwriting practices asked individual market insurers to consider a hypothetical applicant with high blood pressure who also smoked and was overweight. In 60 applications for coverage, this person was rejected 33 times (55%); offered a policy with surcharged premiums 25 times (42%), and offered coverage with no restrictions or premium surcharges twice (3%).