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My family is shopping for new insurance at the moment. We reside in the United States, Georgia specifically. We have had insurance continuously since she was born. My daughter, born in 2011, was born with hip dysplasia and a cleft lip and palate, both considered birth defects. She has had several surgeries, but has no operations scheduled. At the moment we are shopping for individual coverage (I'm self employed) not the exchange.

My question: should one of her doctors decides she needs a procedure or operation of some kind, would that be considered a pre-existing condition, and hence not covered?

Update after talking with Insurance Broker - We are faced with (AFAICT)

  • If we go with an exchange plan - we lose most of our doctors, but the birth defects are not considered pre-existing in any way
  • If we go with a non-exchange plans we get to keep all of our doctors, but any actions related to the birth defects are in a gray area. She has nothing scheduled, pending, or needed at the moment. The only real question is what if a doctor decides that something needs to be done about something related to the birth defect. The broker did not know the answer to that.
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    Do you have health insurance now, and have you had it continuously since she was born? – Ben Miller - Reinstate Monica Dec 4 '17 at 20:08
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    According to my Benefits Coordinator, no. She cannot be denied coverage as of today. However, that might change tomorrow/in the future. – Michael Dec 4 '17 at 22:54
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    Politics aside, if now your current insurance is covering the expenses I would think twice before changing provider. You may be saving some dollars but the risk of "some fine print screwing you" is NOT 0%, running easy math you'll see that you'd need to be saving big to consider a change. – Caterpillaraoz Dec 5 '17 at 10:37
  • Alas, our current provider, Harken Health (a division of United Health Care) is going out of business and is not an option. – Steve French Dec 6 '17 at 14:51
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No. Since 2014, the concept of pre-existing conditions affecting coverage or rates no longer exists in the US:

Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.

These rules went into effect for plan years beginning on or after January 1, 2014.

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    To put it more explicitly, there's no question of "whether something is a pre-existing condition or not". The way the law precluded discrimination based on preexisting conditions is not by defining a blacklist of things insurers can't discriminate based on, but rather by mandating that no one can be excluded from coverage, and that price cannot be based on anything but age and smoker/non-smoker status. – R.. Dec 5 '17 at 4:16
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    Your answer applies only to the last three words of the question, yet you are presenting it as if it applies to the whole question. – Acccumulation Dec 5 '17 at 5:38
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    @Acccumulation - the way I interpreted it, the last sentence is the entire question. (Is she covered?) The rest is just background information. What do you feel I am missing? – TTT Dec 5 '17 at 5:44
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    @Acccumulation Specifically the OP defines "My question" as "should [she need treatment] would that be considered a pre-existing condition, and hence not covered?" – TripeHound Dec 5 '17 at 7:59
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    There's a lot of talk about healthcare changes right now - are you sure that this stays the same in 2018? That is just a few weeks away, so pretty important for the context of the question. – JPhi1618 Dec 5 '17 at 14:45
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From Wikipedia:

In the context of healthcare in the United States, a pre-existing condition is a medical condition that started before a person's health benefits went into effect.

So in your case, no, this would not be considered a pre-existing condition since she has had coverage since birth. A condition that was diagnosed while you're covered by insurance does not become "pre-existing" if you switch insurance companies (there were grace periods for breaks in covereage before ACA and with proposed legislation).

Note that under current law, even if it was a "pre-existing condition", she could not be denied coverage.

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    @TTT We both answer "no". How can one of them be wrong? – D Stanley Dec 4 '17 at 21:22
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    @TTT I'd say your both right. Current law prevents negative ramifications of pre-existing conditions, but even if it didn't (or doesn't in the future), OP's situation is not a pre-existing condition by definition. – Ben Miller - Reinstate Monica Dec 4 '17 at 21:24
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    @TTT All I did was explain what a pre-existing condition is. Is that definition incorrect? – D Stanley Dec 4 '17 at 21:24
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    @stannius the definition has not changed, the treatment has changed. – D Stanley Dec 5 '17 at 16:40
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    @stannius No - if the insured maintains continuous coverage (with some grace allowed) then the condition is not pre-existing. This allows people to switch insurance providers without conditions being reset to "pre-existing". – D Stanley Dec 5 '17 at 18:11

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