Children's Pre-Existing Conditions

Under the Affordable Care Act, health plans cannot limit or deny benefits or deny coverage for a child younger than age 19 simply because the child has a “pre-existing condition” — that is, a health problem that developed before the child applied to join the plan.

This rule applies to all job-related health plans as well as individual health insurance policies issued after March 23, 2010. The rule will affect your plan as soon as it begins a plan year or policy year on or after September 23, 2010.

Some Important Details

• This rule applies whether or not your child’s health problem or disability was discovered or treated before you applied for coverage.
• The new rule doesn’t apply to “grandfathered” individual health insurance policies. A grandfathered individual health insurance policy is a policy that you bought for yourself or your family (and is not a job-related health plan) on or before March 23, 2010.
• Starting in 2014, these protections will be extended to Americans of all ages. Available now: Coverage for adults under the Pre-Existing Condition Insurance Plan.

Example

On October 1, 2010, Sally purchased a new individual health policy for herself and her 13-year-old child, Miranda, who has been treated for asthma in the past. The new health policy excludes coverage for treatment of pre-existing conditions for all enrollees. On November 1, 2010 — one month after coverage began for Sally and Miranda—Miranda is hospitalized for an asthma attack. Her insurance company denies payment for the hospitalization, because under the policy Miranda’s asthma is considered a pre-existing condition.

Under the new law, the insurer can’t deny payment for the hospitalization based on Miranda’s pre-existing asthma condition. Miranda is under the age of 19. Sally’s policy is new and therefore subject to the pre-existing condition rules of the new health care law. Sally’s policy year began after September 23, 2010, when the law’s rules on pre-existing conditions took effect.

For More Information

• Alycia's Story: Peace of Mind in Knowing a Sick Child Won't Be Denied Health Coverage.
• Fact Sheet: Families with Children and the Affordable Care Act.
• Read a Q&A on enrollment of children under 19.
• Read the regulation (detailed legislative information).
• Learn more about the important consumer protections in the Patient’s Bill of Rights.

Posted on: September 23, 2010

Last updated: August 2, 2012