Coverage Guide
Pre-Existing Conditions and Health Insurance in Iowa
Can you be denied health insurance if you have a pre-existing condition? In Iowa, for any ACA-compliant plan, the answer is no. Since 2014, the Affordable Care Act has barred insurance companies from denying coverage, charging more, or imposing waiting periods because of a medical condition, whether that is diabetes, asthma, a cancer history, depression, or pregnancy. This page explains the current rules, the one rating factor that still exists, and the few plan types where health status still matters.
How the ACA Protects People With Pre-Existing Conditions
Every individual and group health insurance plan sold on or off the Health Insurance Marketplace, including employer-sponsored group coverage, must accept you regardless of medical history. Specifically, an insurer cannot:
- Deny you coverage or refuse renewal because a health condition exists
- Charge higher premiums for individuals based on health status or claims history
- Exclude treatment or impose waiting periods specific to the condition
- Cap the essential health benefits with annual or lifetime dollar limits
In short, every compliant plan must cover pre-existing conditions from day one. These protections bind all individual market insurers in the state: Wellmark, Medica, Oscar, Avera, Iowa Total Care (Ambetter), and UnitedHealthcare. Preventive care is also covered at no cost on every compliant plan.
Tobacco Use: The One Surcharge That Remains
Health status cannot affect your rate, but tobacco use can. Iowa law follows the federal standard allowing insurers to charge tobacco users up to 50% more, typically defined as using tobacco four or more times per week in the past six months. Quit-tobacco programs can remove the surcharge at renewal, and we flag which carriers handle this most generously.
Note: This page is included as a reference; pre-existing condition clauses still apply to grandfathered or group/company plans from before 2014, as well as short-term insurance plans.
Blue Cross Blue Shield of Iowa — Pre-Existing Condition Exclusions
Definition
Pre-existing conditions are those health conditions which were diagnosed or treated by a provider during the 12 months prior to the coverage effective date, or for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis or treatment.
⚠ Waiting Period: Any Pre-Existing Condition will be subject to a waiting period of 365 days.
Exception for Prior BCBSIA Group Plan Coverage
For applicants with continuous prior coverage (no more than a 31 day gap) under a Blue Cross and Blue Shield of Iowa employer-sponsored plan, Blue Cross and Blue Shield of Iowa provides credit against the individual plan pre-existing condition exclusion waiting period.
Example
If you enroll in a Blue Cross and Blue Shield of Iowa “individual” plan after being continuously covered for 6 months under a Blue Cross and Blue Shield of Iowa employer group health plan, you’ll be considered to have satisfied 6 months of the 12 month pre-existing condition exclusion waiting period.
Maternity Exception
This exception works for maternity as well. If you were insured under an employer’s BCBSIA group health plan for a year or more, and you immediately enroll in a BCBSIA individual plan with the maternity option, you’ll have no waiting period for the maternity benefits.
Where Health Status Still Matters
A few plan types sit outside these rules, and this is where people get surprised:
- Short-term plans: medically underwritten, and they exclude pre-existing conditions outright. Fine for a healthy-person gap; wrong for managing a condition. See our short-term coverage guide.
- Medicare supplements: outside your one-time Medigap window, carriers can underwrite based on medical history. Details on our Medicare page.
- Grandfathered plans: a shrinking set of pre-2010 grandfathered plans keep their old rules until they terminate.
- Workers’ compensation: a separate system entirely; a pre-existing condition can complicate a claim, but that is employment law, not your health plan.
Before the ACA: HIPIOWA and Underwriting History
Before 2014, Iowa carriers could underwrite individual applicants, decline dozens of diagnoses, attach exclusion riders, and impose 12-month waiting periods, and the state of Iowa ran HIPIOWA, a high-risk pool (including HIPIOWA-FED) as the insurer of last resort for people who were turned down, including HIV patients. Health reform made all of that obsolete: HIPIOWA closed to new business because nobody can be turned down anymore. If you were declined years ago and have stayed uninsured or stuck on an old policy, you have full access to health insurance coverage today.
Mental Health Counseling Guidelines
BCBSIA is extremely strict (and in our opinion, often unfair) on how they underwrite individuals whom have had mental health counseling.
Currently in Counseling
Individuals currently in counseling with a licensed therapist or psychologist will be automatically declined, regardless of the reason they are in counseling.
Recovery Timeline
BCBSIA will only consider accepting an individual after they have completed their treatment for at least 6 months, and acceptance will be based on the original diagnosis/reason for treatment.
Example: An individual completing marriage counseling would most likely be accepted while an individual completing counseling for a drug addiction would not.
Medical Condition Rejection List
If you have a condition, illness, or injury that is listed below, you will most likely be declined for individual coverage with Blue Cross Blue Shield of Iowa. These conditions include, but are not limited to:
| ✗AIDS | ✗Alcoholism/Alcohol Abuse (within 7 years) | ✗Angioplasty |
| ✗Aortic Stenosis | ✗Arteriosclerotic Heart Disease | ✗Ascites (within 5 years) |
| ✗Bi-Polar Disorder | ✗Boecks Sarcoidosis | ✗By-pass surgery |
| ✗Cancer (other than skin cancer)/Malignant Melanoma | ✗Cerebral Vascular Accident | ✗Cerebral Vascular Disease |
| ✗Chronic Obstructive Pulmonary Disease (if currently smoking) | ✗Chronic Pancreatitis | ✗Chronic Renal Failure |
| ✗Cirrhosis of Liver | ✗Coronary Heart Disease | ✗Cushing’s Syndrome |
| ✗Cystic Fibrosis | ✗Diabetes (managed with any type of medication) | ✗Drug Addiction/Abuse (within 5 years) |
| ✗Fatty Liver (hepatic steatosis) | ✗Grand Mal Epilepsy (within 5 years) | ✗Heart Attack |
| ✗Height and Weight (see chart) | ✗Hemodialysis/Peritoneal Dialysis | ✗Hemophilia |
| ✗HIV | ✗Hodgkins Disease | ✗Huntington’s Chorea |
| ✗Immune Deficiency Syndrome | ✗Leukemia (within 7 years) | ✗Liver Atrophy |
| ✗Lupus Erythematosus (Systemic) | ✗Multiple Neurofibromatosis (within 7 years) | ✗Multiple Sclerosis |
| ✗Muscular Dystrophy | ✗Myasthenia Gravis | ✗Myocardial Infarction |
| ✗Nephrosclerosis | ✗Organic Brain Disorder | ✗Pacemaker |
| ✗Paget’s Disease | ✗Parkinson’s Disease | ✗Pending surgery of any kind |
| ✗Peripheral Vascular Disease | ✗Polycystic Kidney | ✗Pregnancy (current) |
| ✗Psychotic Disorder | ✗Rheumatic Heart Disease | ✗Stroke |
| ✗Systemic Scleroderma | ✗Tetralogy of Fallot | ✗Transient Ischemic Attack (within 5 years) |
| ✗Organ Transplants | ✗Valve Replacement |
How to Get Covered With a Pre-Existing Condition in Iowa
- Enroll on time. Open Enrollment runs November 1 to January 15. Miss it, and you need a qualifying life event for a special enrollment period, or Medicaid if you qualify on income (no sign-up window applies there).
- Match the plan to the condition. We check that your doctors, hospital, and prescriptions sit in network and on formulary, and weigh prior authorization rules for your medications.
- Use the subsidy. Premium tax credits on ACA marketplace plans work the same regardless of health status; aca pre existing conditions iowa protections plus a subsidy often beat what people expect to pay.
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