Despite the many answers on this site saying pre-existing conditions are a thing of the past, there are non-marketplace US insurance plans that exclude pre-existing conditions on a 12 month or 24 month look-back, such as short-term plans.

My question is about what happens if you take such a plan and have a condition that is excluded from your coverage. Do you still get charged the "insurance rate" for the appointment/treatment or are you charged full price as if you had no insurance at all?

  • Could someone explain the down vote? I searched for similar questions, then posted a self-answered question when I had to go elsewhere to get the information. Or do they want me to link all the answers here that say pre-existing condition exclusions no longer exist?
    – Dragonel
    Jun 16, 2022 at 19:28
  • ACA doesn't just apply to plans sold on the 'marketplace', my impression was that the only exception for pre-existing conditions was with grandfathered plans, where is a new plan I can purchase that will exclude pre-existing conditions?
    – Hart CO
    Jun 16, 2022 at 19:41
  • 1
    @HartCO that's not true. ACA doesn't apply to short term plans or other non-compliant plans, but these plans are not allowed to the ACA marketplaces.
    – littleadv
    Jun 16, 2022 at 22:00
  • I didn't downvote, but generally this question can only be answered by your insurance provider and the doctor's billing service
    – littleadv
    Jun 16, 2022 at 22:01
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    @HartCO - I'm looking at them at the moment because of a temporary loss of coverage while changing jobs. The main reason someone would choose them is that they are substantially cheaper than ACA plans, but of course you are getting less coverage
    – Dragonel
    Jun 17, 2022 at 15:22

2 Answers 2


Short term medical insurance isn’t health insurance, really, it’s accident insurance that functions like your car insurance. It also, generally (because I’m sure somewhere there’s an exception and someone will comment that this or that exists), isn’t offered by your typical health insurance companies. I.E. you can’t buy Aetna short term coverage. In some states this short term coverage is actually illegal to sell. Short term coverage is not skinny coverage, which functions exactly like your regular health insurance but has various limits, either dollar or service frequency limits.

People I’ve seen buy short term coverage are ex-pats who are returning to the US for several months at a time, or younger people who are healthy and don’t want to pay for COBRA, and live in a state where it’s not illegal to sell; which seems to be your situation.

There are absolutely pre-existing condition limitations. The ones I’m aware of also exclude any coverage for COVID treatment, and contain other general act of war, self-inflicted injury type exclusion language along with that 12/24 look back language. Again, this is not medical insurance. It is not intended to get you your annual physical or get you through a cancer diagnosis and associated treatment. It exists, really, to patch you up after a mountain biking accident or whatever while you wait for eligibility through your next employer.

I’ve seen some that have a contracted network, but there’s no incentive to use the in-network providers apart from the pre-negotiated rates. Coverage I’ve seen is priced with a pretty simple matrix of age and maximum, with different rate sheets for deductible and coinsurance percent. So a $1,000 deductible 90% coinsurance plan will have a rate sheet with ages and prices at each maximum of $250k, $500k, $1mm, etc limits.

A short term plan that I’ve also seen that’s less illegal and more like health coverage is a Medicare bridge plan. It’s at least somewhat common for an older working person to retire while they have a spouse who’s more than 36 months away from their own Medicare eligibility; so COBRA can’t cover the spouse for the entire time between the breadwinner retiring and the spouses own eligibility. Medicare bridge plans tend to have a provider network and basically mirror Medicare coverage but still run more like indemnity coverage.

Anyway, yes assuming you live in a state where it’s legal to sell short term coverage, your pre-existing condition is excluded from coverage. If your plan has a provider network (again, a lot of these options don’t) you can use that network for pre-negotiated rates. A common network for these kinds of plans that has a network is called Multiplan, generally referred to as MPN (other big carriers and employer health plans use multiplan too).

If pre-existing conditions are a concern for you there exists now ACA conforming coverage available to you on a potentially subsidized basis in all 50 states. Short term coverage might not be the route to take. If you have a pre-existing condition you can definitely buy coverage that will include it, this was not always the case.

  • This is all great info, but I'm not sure it answers the question. If the insurance covers things X,Y, and Z, and there is a discounted rate with providers for Z, but someone has a pre-existing condition of Z and therefore is only covered for X and Y, does that person still get the negotiated discounted rate with their provider for service for Z? (That is the question here, I think.)
    – TTT
    Jul 18, 2022 at 22:20
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    @TTT the second to last paragraph, the insurance and the network are two different things. If the short term plan has a provider network, which many don’t, you would get network pricing. Whether any of the pricing is paid (reimbursed really since we’re talking short term coverage which, again, is generally indemnity coverage) by the insurer is a different matter.
    – quid
    Jul 19, 2022 at 7:40
  • Ah. Great. I guess it's implied then, as if you had said (emphasis my own): "you can use that network for pre-negotiated rates, even if you personally aren't covered for that service". That makes sense.
    – TTT
    Jul 19, 2022 at 14:25

I talked to a couple of Insurance Brokers and finally found one who could answer the question.
As far as the insurance company is concerned, you will be charged the full cost. This doesn't preclude you talking to your Doctor's billing office & seeing if they can give you a discount of some sort or a "non-insured" rate for those treatments

  • There's a big difference between a pre-existing condition and one that isn't covered. This is not surprising.
    – JohnFx
    Jun 16, 2022 at 19:06
  • I'm upvoting this answer because it is valuable information, but I absolutely hate what this answer suggests. This, if true, implies that the insurance company will force providers to bill a negotiated rate for some people, and not others. I don't know why the insurance company wouldn't be willing to do this even if they aren't ultimately paying the bill. Imagine the case where neither person has met their deductible yet, so both are paying out of pocket for the service, but the person with a pre-existing condition has to pay more for the same service. That shouldn't even be legal, IMHO.
    – TTT
    Jul 16, 2022 at 19:16
  • To rebut my previous comment, I suppose it could be the case that providers are more likely to do a "self-pay" discount when insurance is flat out denied, so it could end up working out in the person's favor this way, if they know that they should at least ask for a discount. And, whether I like it or not it may be a little odd for an insurance company to say, "We're denying this claim, but by the way, you should charge this discounted price for the service." ;)
    – TTT
    Jul 16, 2022 at 20:34

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