Pre-existing Conditions Under ACA: Quick Fact

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The ACA currently protects individuals from being denied coverage due to pre-existing conditions. Specifically, it prohibits both exclusions of coverage of specific benefits and complete exclusions from a plan or coverage based on a pre-existing condition.

The AHCA retains these protections. However, it would allow issuers in states that receive waivers of the community rating rules to charge higher premiums for individuals with pre-existing conditions, in some cases. The AHCA would establish a fund to provide assistance to individuals that have higher premiums due to pre-existing conditions under these circumstances.

The majority of the ACA would not be affected by the AHCA. The MacArthur amendments specifically maintain most of the ACA’s market reforms. For example, the following key ACA provisions would remain in place:

  • Cost-sharing limits on essential health benefits (EHBs) for non-grandfathered plans (currently $7,150 for self-only coverage and $14,300 for family coverage)
  • Prohibition on lifetime and annual limits for EHBs
  • Requirements to cover pre-existing conditions
  • Coverage for adult children up to age 26
  • Guaranteed availability and renewability of coverage
  • Nondiscrimination rules (on the basis of race, nationality, disability, age or sex)
  • Prohibition on health status underwriting

Age rating restrictions would also continue to apply, with the age ratio limit being revised to 5:1 (instead of 3:1), and states would be allowed to set their own limits. The MacArthur amendments also reinstate EHBs as the federal standard, eliminating a prior controversial amendment to the AHCA, although states may obtain waivers from these rules.

AUI will keep you updated with any applicable legislative developments.

2019-03-07T20:30:55-05:00