High cholesterol is a common health concern for many individuals, and understanding its implications, particularly regarding health insurance, is a frequent question. Around 10% of adults aged 20 or older in the United States had high total cholesterol between 2017 and 2020. This condition often prompts questions about how it might affect insurance coverage, specifically whether it qualifies as a “pre-existing condition.”
Defining a Pre-existing Condition
A pre-existing condition generally refers to any medical issue for which an individual received diagnosis, advice, or treatment before their new health insurance plan began. This definition historically allowed insurers to deny coverage or charge higher rates for certain conditions. Common examples of conditions that were often classified as pre-existing include chronic illnesses such as asthma, diabetes, cancer, and even conditions like anxiety or sleep apnea. Insurers would typically review an applicant’s medical history, treatment records, and diagnosis reports to determine if a condition qualified as pre-existing. This historical classification was a significant factor in how individuals accessed and afforded healthcare.
High Cholesterol: A Common Health Concern
Cholesterol is a waxy, fat-like substance present in the blood, necessary for building healthy cells. However, high levels of certain types of cholesterol can pose health risks. Low-density lipoprotein (LDL) cholesterol, often referred to as “bad” cholesterol, can contribute to plaque buildup in the arteries, a process called atherosclerosis. This buildup can narrow or block arteries, increasing the risk of heart disease and stroke.
High cholesterol often presents without noticeable symptoms, meaning individuals may not realize they have it until diagnosed. Diagnosis is typically made through a simple blood test called a lipid panel, which measures total cholesterol, LDL cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides. For instance, a total cholesterol level of 240 mg/dL or more is considered high.
How High Cholesterol is Classified by Insurers
If high cholesterol was diagnosed or treated before the effective date of a new health insurance plan, it was historically considered a pre-existing condition. This classification was based on the timing of the diagnosis or treatment relative to the policy’s start date. Insurers would examine medical records to determine if the condition existed prior to enrollment. This could include any symptoms, medication use, advice, or tests related to cholesterol.
Prior to the Affordable Care Act (ACA), insurance companies could use this pre-existing condition classification to their advantage. They might have denied coverage outright, charged significantly higher premiums, or imposed waiting periods before covering treatments related to high cholesterol. This meant that individuals with a pre-existing diagnosis of high cholesterol could face substantial barriers to obtaining comprehensive health insurance. The crucial factor was whether the condition was known or treated before the new policy began, which dictated how insurers would handle coverage.
Healthcare Laws and Pre-existing Conditions
The landscape for pre-existing conditions, including high cholesterol, changed significantly with the Patient Protection and Affordable Care Act (ACA) enacted in 2010. The ACA made it illegal for most health insurance plans to deny coverage, charge more, or limit benefits based on an individual’s health status, including pre-existing conditions. This applies to plans sold on the Health Insurance Marketplace and most employer-sponsored plans.
Under the ACA, individuals with high cholesterol can generally obtain coverage without facing denial or exorbitant rates due to their condition. This ensures that treatment for pre-existing medical conditions is covered from the day the plan begins. The law also prohibits waiting periods for pre-existing conditions, allowing immediate access to necessary treatments. These protections have greatly expanded access to health insurance for millions of Americans managing various health conditions.