Statement from HHS Secretary Sebelius on International Day of Persons with Disabilities

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.

What This Means for You

Until now, plans could refuse to accept anyone because of a pre-existing health condition, or they could limit benefits for that condition.

Now, under the health care law, plans that cover children can no longer exclude, limit, or deny coverage to your child under age 19 solely based on a health problem or disability that your child developed before you applied for coverage. 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.

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

• 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.

The Affordable Care Act stops health plans from retroactively canceling your insurance coverage solely because you or your employer made an honest mistake on your insurance application.

What This Means for You

Before the health care law, if your insurance company found that you’d made a mistake on your insurance application, the insurance company might “rescind” your benefits — that is, declare your policy invalid from the day it began. Your insurance company might also ask you to pay back any money already spent for your medical care.

Now, an insurer cannot rescind your coverage simply because you made an honest mistake or left out information that has little bearing on your health.

Some Important Details

• This provision applies to all health plans, whether you get coverage through your employer or purchase it yourself.
• This provision applies to plan years or policy years that begin on or after September 23, 2010. To find out when your plan year or policy year begins, ask your insurer or plan administrator.
• Your insurance company can still rescind your coverage if you intentionally put false or incomplete information on your insurance application, and it can cancel your coverage if you fail to pay your premiums on time.
• Your insurance company must give you at least 30 days’ notice before it can rescind your coverage, giving you time to appeal the decision or find new coverage.

Example

When her insurance application asked for “anything else relevant to your health that we should know about,” Katy forgot to mention two visits to a psychologist she had 6 years earlier. Katy was later diagnosed with breast cancer, and submitted claims to her insurance company for breast cancer treatment. After receiving Katy’s claim, her plan discovered the two psychologist visits. Before the new law, Katy’s mistake might have prompted her health insurer to rescind, or retroactively cancel, her coverage. But under the health care law, Katy’s insurance plan cannot rescind her coverage, because Katy did not intentionally misrepresent significant information.

For More Information

• Read the regulation (detailed legislative information).

• Learn more about the important consumer protections in the Patient’s Bill of Rights.