Pre-Existing Conditions: Here’s What You Need to Know Pre-existing conditions have been prominent in the news lately and much of the discussion includes some misunderstandings about what it actually means to protect coverage of pre-existing conditions and why it matters. While Medicare and Medicaid cover pre-existing conditions and that coverage is not under threat, ther e ar e changes in laws and regulations, and even a pending court case, that do put coverage at risk for millions of people in the United States who are covered by employer or individual insurance. Polling consistently finds that Americans want protections for pre-existing conditions, with 75% of the public saying it’s “very important” such protections remain law. But ther e is a lot of confusion about what this means. Pre-existing conditions are health problems that a person has before they become insured by a particular insurer. For example, if a person who has asthma gets a new job with new health insurance, their asthma is a preexisting condition. Historically, insurers have chosen not to cover pre-existing conditions whenever
possible, but there are laws in effect that require insurers to cover them under most circumstances. Before the Affordable Care Act (ACA) was passed, individual plans often completely excluded coverage for pre-existing conditions, meaning the consumer could buy the insurance policy but would have coverage only for new conditions. Some insurers would cover pre-existing conditions but would charge exorbitant rates for the coverage. In other cases, the insurers refused to sell the policy at all to some consumers. For employer plans, most new employees faced waiting periods of up to a year before their preexisting conditions would be covered unless they were already insured. One of the strongest consumer protections from the ACA is the requirement that insurers cover pre-existing conditions in products sold to employers or the individual market without exclusions, waiting periods, price hikes, or denials. This opened up the insurance market to millions of people who could not get coverage before. In 2017, Congressional
Republicans and the Trump administration supported bills that would have repealed the ACA and eliminated these protections. Again, without the ACA in place, many people with preexisting conditions could not find coverage, either because they were rejected or because they could not afford the premiums. While those attempts to repeal the ACA in 2017 failed, there are now whispers that the effort is not yet dead and that Congress may return to repeal in 2019. Even without repeal, the Trump administration has taken many steps to decrease the protection of the ACA by expanding shortterm and association plan availability and, as of this week, providing federal funding to allow people to buy plans that do not cover preexisting conditions at all. In addition, the administration is supporting a lawsuit that would eradicate the ACA’s protections for pre-existing conditions entirely. Thr eats to this vital coverage are coming from all directions at once. Larry Levitt of the Kaiser
Family Foundation lays out important things to consider when health insurance claims to cover pre-existing conditions: Does it guarantee access to coverage irrespective of health? Does it require community rating, meaning the same premiums for people who are healthy and sick? Does it mandate a package of required benefits? Can insurers exclude coverage of preexisting conditions? Are annual and lifetime limits on coverage allowed? Medicare, Medicaid, and ACA-compliant plans pass these tests but some of the new insurance offerings do not. It’s important that anyone in the market for new insurance understand how the plan works and what it might exclude. Read more about short-term and association plans. Read more about how the ACA changed employer coverage. Read more about what it means to protect pre-existing conditions.
How Prior Authorization Can Impede Access to Care in Medicare Advantage While Medicare Advantage (MA) plans are required to cover the same health services as Original Medicare, they are not required to offer the same level of provider access and can impose coverage restrictions— like prior authorization—that require enrollees to take additional steps before accessing prescribed care. If a service is covered “with prior authorization,” enrollees must get approval from the plan prior to receiving the service. If approval is not granted or sought, the plan generally will not cover it. A new analysis from the Kaiser Family Foundation looks
at the prevalence of prior authorization in MA and found that many plans utilize this flexibility: 80% of MA enrollees are in plans that require prior authorization for at least one Medicare-covered service. Original Medicare, in contrast, does not require prior authorization for the vast majority of services, making this an important distinction between the two coverage options. In some instances, prior authorization may be an appropriate utilization management tool. In particular this is true when both beneficiaries and providers are
likely to benefit from advance knowledge of Medicare coverage. However, MA’s broad application of prior authorization can impede access to care. On our National Helpline, we frequently hear from MA enrollees who are experiencing a range of denials for healthrelated services, and who are concerned and confused about their plan’s service denials and coverage requirements. While each MA plan has different rules, as the KFF report indicates, many require enrollees to obtain approval before
receiving an array of critical services: At least 70% of enrollees are in plans that require prior authorization for Part B drugs and inpatient hospital stays. 60% of enrollees are in plans that require prior authorization for ambulance, home health, procedures, and laboratory tests. More than half of enrollees are in plans that require prior authorization for mental health services….Read More
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