Pre - Existing denial - CO 51

CO - 51 These are non-covered services because this is a pre-existing condition. Denial and Action


Pre-existing condition refers to the terms and conditions entered in to between the carrier and the patients/subscribers before the beginning of the contract.  The rejection will usually say that the claim is being denied due to the pre-existing condition.  It would not specify what exactly; the condition is.  So carrier needs to be called to find out the pre-existing condition. Preexisting condition may be for anything.


A). there may be a condition that for the first $5000 worth of medical expenses the patient should bear it himself and the carrier would start paying for expenses after crossing the limit.  If the patient has not yet exhausted the threshold limit then the claim would be denied for the pre-existing condition.

B). there may be a condition that the carrier would not be paying for the same diagnosis more that once in a year. If a same diagnosis code is used on two occasions in the same year then the carrier will deny the claim submitted for the second time stating pre-existing condition.

    Action:  as soon as you receive the denial,  check with insurance on the pre-existing condition. If the patient has secondary coverage with the secondary if we can send the entire bill to secondary along with the primary denial.  Some carriers may be willing to pay for the same.  If the patient has no secondary coverage/ secondary refused to pay the request you to bill the patient.

pre-existing condition

In group health insurance, generally a condition for which an individual received medical care during the three months immediately prior to the effective date of coverage

screening programs

Preventive care programs designed to determine if a health condition is present even if a member has not experienced symptoms of the problem.

Pre-Existing Conditions:

The Impact of the Affordable Care Act

The Affordable Care Act (ACA) put in place a range of nationwide protections for Americans with pre-existing health conditions. Under the ACA, insurance companies cannot deny coverage or charge higher premiums based on a person’s medical history or health status. In addition, policies cannot exclude coverage for treating a pre-existing condition, must include limits on outof-pocket spending, cannot include limits on annual or lifetime coverage, and, in the case of most individual and small group market policies, must cover essential health benefits.

In 2011, prior to the implementation of the ACA’s major health insurance reforms in 2014, ASPE examined the impact of the ACA’s pre-existing conditions protections.

The 2011 analysis found that between 50 and 129 million non-elderly Americans had pre-existing health conditions and would gain new protections under the ACA reforms.2

This analysis updates that earlier study. It confirms that a large fraction of non-elderly Americans have pre-existing health conditions: at least 23 percent of Americans (61 million people) using a narrow definition based on eligibility criteria for pre-ACA state high-risk pools, or as many as 51 percent (133 million people) using a broader definition closer to the underwriting criteria used by insurers prior to the ACA. Any of these 133 million Americans could have been denied coverage, or offered coverage only at an exorbitant price, had they needed individual market health insurance before 2014. This analysis also offers a first look at how health insurance coverage for people with pre-existing conditions actually changed when the ACA’s major insurance market reforms took effect in 2014. It finds that, between 2010 and 2014, the share of Americans with pre-existing conditions who went without health insurance all year fell by 22 percent, a drop of 3.6 million people. The ACA’s individual market reforms appear to have played a key role in these gains.

After dropping by about a quarter between 2010 and 2014, the uninsured rate for all non-elderly Americans has fallen an additional 22 percent through the first half of 2016.3 While data for Americans with pre-existing conditions are available only through 2014, it is likely that this group has also seen continued gains in access to coverage and care over the past two years.

Key Findings:

* Up to 133 million non-elderly Americans—just over half (51 percent) of the non-elderly population—may have a pre-existing condition. This includes 67 million women and girls and 66 million men and boys.

* The likelihood of having a pre-existing condition increases with age: up to 84 percent of those ages 55 to 64—31 million individuals—have at least one pre-existing condition.

* Among the most common pre-existing conditions are high blood pressure (46 million people), behavioral health disorders (45 million people), high cholesterol (44 million people); asthma/chronic lung disease (34 million people), heart conditions (16 million people), diabetes (13 million people), and cancer (11 million people).

* Between 2010 and 2014, when the ACA’s major health insurance reforms first took effect, the share of Americans with pre-existing conditions who went uninsured all year fell by 22 percent, meaning 3.6 million fewer people went uninsured.

* Tens of millions of Americans with pre-existing conditions experience spells of uninsurance. About 23 percent (31 million) experienced at least one month without insurance coverage in 2014, and nearly one-third (44 million) went uninsured for at least one month during the two-year period beginning in 2013.

How the ACA Reformed Coverage for People with Pre-Existing Conditions

A pre-existing condition is a health condition that predates a person applying for or enrolling in a new health insurance policy. Before the ACA, insurers generally defined what types of conditions could constitute a pre-existing condition. Their definitions frequently encompassed both serious conditions, such as cancer or heart disease, and less severe and more common conditions, such as asthma, depression, or high blood pressure.

Before the ACA, individual insurers in the vast majority of states could collect information on demographic characteristics and medical history, and then deny coverage, charge higher premiums, and/or limit benefits to individuals based on pre-existing conditions. An industry survey found that 34 percent of individual market applicants were charged higher-than-standard rates based on demographic characteristics or medical history. 4 Similarly, a 2009 survey found  that, among adults who had individual market coverage or shopped for it in the previous three years, 36 percent were denied coverage, charged more, or had exclusions placed on their policy

due to pre-existing conditions. 5 A report by the Government Accountability Office estimated that, as of early 2010, the denial rate among individual market applications was 19 percent, and the most common reason for denial was health status.6

While some states attempted to offer some protection to people with pre-existing conditions, these efforts were generally not effective at ensuring access to affordable coverage.7 For example:

* Some states required that coverage be offered to people with pre-existing conditions, but imposed no restrictions on how much insurers could increase premiums based on health status.

* Some states required that coverage be offered to people with pre-existing conditions, but allowed insurers to exclude treatment for the pre-existing condition. Thus, a cancer survivor could have obtained coverage, but that coverage would not have paid for treatment if the cancer re-emerged.

* Some states required that coverage be offered to people with pre-existing conditions, but only to those who met continuity of coverage requirements. In practice, a high fraction of people with pre-existing conditions go uninsured for at least short spells due to job changes, other life transitions, or periods of financial difficulty. About 23 percent of percent of Americans with pre-existing conditions (31 million people) experienced at least one month without insurance coverage in 2014. In the two-year period beginning in 2013, nearly one-third (44 million) of individuals with pre-existing conditions went uninsured for at least one month. About 93 percent of those who were ever uninsured went without coverage for a spell of two months or more, and about 87 percent went without coverage for a spell of three months or more.8

* A few states sought to require that people with pre-existing conditions be offered coverage at the same price as other Americans. But without accompanying measures to ensure that healthy residents also continued to buy insurance, these states saw escalating premiums that made health insurance unaffordable for sick and healthy residents alike.9

In contrast, the ACA implemented a nationwide set of reforms in the individual health insurance market. The law requires individual market insurers to offer comprehensive coverage to all enrollees, on common terms, regardless of medical history. Meanwhile, the ACA also includes measures to ensure a balanced risk pool that keeps coverage affordable. To directly improve affordability while encouraging individuals to buy coverage, the ACA offers financial assistance for eligible taxpayers with household incomes up to 400 percent of the federal poverty level to reduce their monthly premium payments. 10 The law also includes an individual shared responsibility provision that requires people who can afford coverage to make a payment if they instead elect to go without it.11

Prevalence of Pre-Existing Conditions

Estimating the Number of Americans with Pre-Existing Conditions This analysis updates earlier ASPE estimates of the number of non-elderly Americans potentially benefitting from the ACA’s pre-existing conditions protections. As in the earlier study, we consider two definitions of pre-existing conditions. The narrower measure includes only conditions identified using eligibility guidelines from state-run high-risk pools that pre-dated the ACA. These programs were generally intended to cover individuals who would be outright rejected for coverage by private insurers. The broader measure includes additional common health conditions (for example, arthritis, asthma, high cholesterol, hypertension, and obesity) and behavioral health disorders (including alcohol and substance use disorders, depression, and Alzheimer’s) that could have resulted in denial of coverage, exclusion of the condition, or higher premiums for individuals seeking individual market coverage before the ACA protections

applied.12

We focus primarily on the broader measure, because individuals with any of these conditions were at risk of higher premiums and/or coverage carve-outs, if not outright coverage denials if they sought individual market health insurance before the ACA protections applied. The narrower measure is similar to that used in a recent Kaiser Family Foundation (KFF) analysis, which finds that 52 million non-elderly adults would have been “uninsurable” in the individual market in most states before the ACA. The KFF study notes that its analysis does not attempt to include “people with other health conditions that wouldn’t necessarily cause a denial, but could

lead to higher insurance costs based on underwriting.”13

Both our narrow and broad estimates are based on the 2014 Medical Expenditure Panel Survey (MEPS), the most recent data available that provide both coverage and detailed health status information. The appendix provides a more detailed description of our methodology and supplemental tables.14

The Prevalence of Pre-Existing Conditions in 2014

As shown in Table 1, we find that the ACA is protecting between 23 and 51 percent of nonelderly Americans--61 to 133 million people--with some type of pre-existing health condition from being denied coverage, charged significantly higher premiums, subjected to an extended waiting period, or having their health insurance benefits curtailed should they need individual market health insurance coverage.

Certain groups are more likely than others to have pre-existing conditions. In particular, as people age, their likelihood of having—or ever having had—a pre-existing health condition increases steadily. Americans between ages 55 and 64 are particularly at risk: 49 to 84 percent of people in this age range—up to 31 million people—have some type of pre-existing condition. By comparison, 6 to 24 percent of Americans under the age of 18 have some type of pre-existingcondition (see Figure 1). Approximately 56 percent of Non-Hispanic whites and individuals with family incomes above 400 percent of the federal poverty level have some type of pre-existing

condition.

Common Pre-Existing Conditions Facing Americans

As shown in Table 2, we also examine the prevalence of specific pre-existing conditions faced by Americans (focusing on the broader insurer definition). The table lists the eleven conditions with prevalence of 1 million or more among non-elderly individuals with no Medicare enrollment during 2014. These conditions are listed from most to least prevalent, although differences between ranks may not be statistically significant.

The Impact of the ACA’s Protections in 2014

As described above, the ACA put in place a range of new protections designed to give individuals with pre-existing conditions, along with other Americans, increased access to affordable health insurance. The 2014 MEPS data show that this is being borne out in practice, with significant improvements in health insurance coverage for Americans with pre-existing conditions.

As shown in Table 3, between 2010 and 2014, the share of Americans with pre-existing conditions who went uninsured all year fell from 13.8 percent to 10.7 percent, a drop of 22 percent. These gains translated into 3.6 million fewer individuals with pre-existing conditions without health insurance.

Conclusion

With data available only through 2014, this analysis provides a preliminary picture of how the ACA is helping individuals with pre-existing conditions. The uninsured rate for all Americans, which fell by 27 percent between 2010 and 2014, fell another 22 percent between 2014 and 2016, and people with pre-existing conditions have likely seen similar additional progress. Nonetheless, this initial snapshot confirms that the ACA’s insurance market reforms are providing important protections to the up to half of Americans whose medical history previously put them at risk of being denied access to affordable health care.