State RegulationsNY specificDifficulty 2/5
An Albany woman discloses a treated heart condition on her application for individual major medical coverage. Under the Affordable Care Act, how may the insurer respond to her preexisting condition?
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Answer & full 3-part explanation (select an option above, or peek)
Why B is correct
Under the Affordable Care Act, insurers in the individual and small-group markets cannot use health status or medical history in underwriting. Coverage is guaranteed issue, so the insurer may not deny the application, exclude the heart condition, impose a preexisting-condition waiting period, or rate the premium up because of it. The New York Department of Financial Services supervises compliance with these protections for coverage delivered in New York.
Why the other options are wrong
- A) A preexisting-condition waiting period is prohibited under the Affordable Care Act, which bars insurers from excluding listed conditions.
- C) Denying the application because of health history is exactly the underwriting practice the Affordable Care Act prohibits.
- D) Requiring a medical examination to get the condition covered is health-status underwriting, which the Affordable Care Act forbids.
Memory hook
Guaranteed issue slams the door on preexisting-condition underwriting.