Which private health plans in 2025 still use medical underwriting or exclude pre-existing conditions?
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Executive summary
Most mainstream private health plans sold on the ACA Marketplace and employer-sponsored group plans in 2025 cannot deny coverage or exclude pre‑existing conditions because federal law forbids it [1] [2]. However, a distinct set of private products — primarily short‑term limited‑duration plans, fixed‑indemnity and other limited‑benefit policies, certain supplemental or travel plans, legacy “grandfathered” or “grandmothered” contracts, and some Medigap/ancillary products — still use medical underwriting or impose exclusions or waiting periods for pre‑existing conditions [3] [4] [5] [6].
1. The baseline: ACA‑compliant individual and group plans — guaranteed issue and no exclusions
All individual Marketplace plans must cover treatment for pre‑existing conditions and insurers participating on the Marketplace cannot use health status to deny or charge more to enrollees, and group plans similarly are barred from excluding or charging differently for pre‑existing conditions under ACA rules and related federal guidance [1] [2] [7].
2. The predictable exceptions: non‑ACA products that still underwrite
Plans that are not subject to the ACA’s “major medical” rules typically still perform medical underwriting and commonly exclude pre‑existing conditions; these include short‑term limited‑duration insurance, fixed‑indemnity plans, critical‑illness products, and certain travel or limited‑scope supplemental policies, and insurers and brokers explicitly warn that such products can and do exclude coverage based on medical history [3] [5] [6].
3. How exclusions work in practice: moratoria, exclusion riders, and post‑claims underwriting
Non‑compliant plans use several approaches: moratorium underwriting (temporary exclusion of conditions from a look‑back period), exclusion riders that permanently carve out a condition, rate‑ups, and in some cases “post‑claims underwriting” where an insurer accepts an application but later seeks to deny a claim after reviewing medical history [8] [9] [4]. Consumer guides and insurer disclosures caution buyers to read policy certificates for exclusions and limitations [5] [4].
4. Legacy and specialized policies that can still treat pre‑existing conditions differently
A small number of legacy plans — specifically grandfathered or grandmothered individual policies sold years before ACA implementation — are not required to follow the current rules and historically could have exclusions; those plans have not been sold to new applicants for years but can persist in force for existing enrollees [4] [10]. Separately, Medigap (Medicare Supplement) plans may involve underwriting or waiting periods depending on timing and state rules, meaning that Medicare beneficiaries who lack guaranteed‑issue rights can face underwriting for Medigap [3] [6].
5. Employer self‑insured plans and nuance about who enforces protections
Federal ACA protections apply to group plans, but the practical design of employer‑sponsored benefits — including self‑insured arrangements where the employer bears risk — can involve varying administrative practices; federal summaries note that self‑insurance is an alternative and that some requirements differ in application though pre‑existing condition exclusions were broadly eliminated for group coverage under ACA rules [2].
6. Political and industry context: why limited plans exist and the attendant risks
Insurers and brokers market short‑term and limited products as cheaper, flexible stopgaps, a stance reflected in company pages and consumer advisories that also disclose underwriting and exclusions [5] [6]. Consumer advocates and health policy researchers warn these products can leave people with chronic conditions unprotected and create confusion for buyers who may conflate limited plans with ACA coverage [11] [9]. Federal guidance and state regulation continue to shape availability and features of these products, so the landscape can vary by state and by specific contract language [6] [9].
7. Bottom line and what consumers should watch for in 2025
If a policy is sold on the ACA Marketplace or is a standard employer group plan, pre‑existing condition exclusions should not apply [1] [2]; if a product is short‑term, fixed‑indemnity, critical‑illness, travel, or another limited‑benefit plan, expect medical underwriting, potential exclusion riders, moratoria, or post‑claims review [3] [4] [5] [6]. Public resources and insurer disclosures are the definitive sources for any given product’s rules; reporting here is limited to the materials provided and does not catalog every insurer’s 2025 product filings across states [5] [9].