Pre-existing condition
A health condition that existed before a patient's health coverage enrollment date.
Updated
A pre-existing condition is a health condition, illness, or injury that existed before a patient's enrollment date in a health insurance plan. Examples include asthma, diabetes, and pregnancy present before the coverage effective date.
Under the Affordable Care Act (ACA), health insurance plans sold to individuals and small employers cannot deny coverage, charge higher premiums, or impose coverage exclusions based on pre-existing conditions.
In practice
For ACA-compliant plans, pre-existing condition exclusions are prohibited, so billing teams generally do not apply exclusionary coding for prior conditions on covered services. Grandfathered group plans may still apply pre-existing condition exclusions subject to ACA limits, so eligibility and benefit verification must confirm the plan type.
Commonly confused with
- Essential health benefits: Essential health benefits are categories of services ACA plans must cover; pre-existing conditions relate to the patient's medical history rather than the service categories.