The Affordable Care Act eliminated pre-existing conditions starting 2014. Insurance companies are no longer able to deny coverage, charge more, impose waiting periods, or deny treatment for anyone with pre-existing conditions. The only exceptions are procedures like cosmetic surgery that aren’t considered medically necessary.

The only medical question an insurance company asks that may affect your rates is your tobacco use. If you have used tobacco 4 or more days a week for the past 6 months, an insurance company is allowed to charge you 50% more than a non-tobacco user.

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 Wisconsin

Pre-Existing Condition Exclusions

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.
Any Pre-existing Condition will be subject to a waiting period of 365 days.

Exception for Prior BCBSWI Group Plan Coverage

For applicants with continuous prior coverage (no more than a 31 day gap) under a Blue Cross and Blue Shield of Wisconsin employer-sponsored plan,
Blue Cross and Blue Shield of Wisconsin provides credit against the individual plan pre-existing condition exclusion waiting period.

For example, if you enroll in a Blue Cross and Blue Shield of Wisconsin “individual” plan after being continuously covered for 6 months under a Blue Cross and Blue Shield of Wisconsin employer group health plan, you’ll be considered to have satisfied 6 months of the 12 month pre-existing condition exclusion waiting period.

This exception works for maternity as well. If you were insured under an employer’s BCBSWI group health plan for a year or more, and you immediately enroll in a BCBSWI individual plan with the maternity option, you’ll have no waiting period for the maternity benefits.

Medical Condition-Specific Waivers

If you have a condition, illness, or injury that can be identified as one that does not necessarily affect your overall good health but could affect the risk balance of all insureds, Blue Cross and Blue Shield of Wisconsin may exclude that condition from coverage.
This means that expenses for treatment of that condition or any other condition related to it will not be covered for a specified period of time.

Blue Cross and Blue Shield of Wisconsin will place a maximum of two coverage exclusion riders on any one applicant.
When a policy is conditionally approved with one or two exclusion riders, coverage will not be put in force until the applicant has accepted the offer by signing, dating, and returning the rider along with any other outstanding requirements that may be applicable.

Mental Health Counseling Guidelines

BCBSWI is extremely strict (and in our opinion, often unfair) on how they underwrite individuals whom have had mental health counseling. Individuals currently in counseling with a licensed therapist or psychologist will be automatically declined, regardless of the reason they are in counseling.
BCBSWI 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. For 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 on the Medical Condition Rejection List below, you will most likely be declined for individual coverage with Blue Cross Blue Shield of Wisconsin.

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) (fully recovered with normal lab results for minimum of 6 months)
  • 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