Allergies and Health Insurance

A very common condition that affects millions of Americans, allergies can take many forms and be caused by genetics and/or environmental factors. When the immune system’s response is extremely sensitive, allergic reactions occur, and chemicals such as histamines are released. For those experiencing this overreaction to allergens, which would otherwise not affect most people, allergy symptoms form and become very uncomfortable, sometimes painful. Symptoms are always related to the part of the body affected, whether skin, respiratory system, digestive system or the whole body.

Allergies can be treated in a number of ways, depending on the level of severity. Most treatment involves medication, though avoiding the factors causing your allergic reactions is the best solution, especially for food allergies. Medications for allergies include the common antihistamine or decongestant, as well as corticosteroids, shots, and leukotriene inhibitors. Though medications are typically effective, allergies can lead to anaphylaxis, a life-threatening allergic reaction, complications in breathing while the allergic reaction takes place or negative side effects of a medication.

As allergies are often ongoing, health insurance companies would have increased rates or declined an applicant who has a certain type of allergic reaction in the past. Like all conditions before health reform, allergies could have been the reason a person loses their opportunity to obtain health insurance; mostly based on the seriousness and regularity of treatment. For individuals who receive shots on a monthly basis, the stakes are higher than someone with a seasonal sniffle. However, insurers now have to accept people with all types of allergic reactions.


Allergies and Applying for Individual Health Insurance: Past and Present



Health Reform and Allergies

By eliminating discrimination against health problems in health plan underwriting, the ACA allows any legal citizen or U.S. resident with a pre-existing condition to get covered. The law prohibits any insurer from declining anyone with allergies, and companies are also unable to issue exclusion periods or elimination riders. Health plans can no longer increase your rates by more than 10 percent over the normal premium regardless of your health status. You now have the freedom to choose any health plan on the private market without worrying about rejection notices, benefit restrictions or higher premiums.

The law also helps lower-income Americans through Medicaid expansion in participating states, which opens the program to childless adults. Adults without children or a disability, whose income is at or below 138 percent of the federal poverty line can apply for medical assistance in those states. If you earn more than the Medicaid income limits in your state and can’t afford to buy your own plan, or could use a discount, the exchange in your state can reduce your premium and medical expenses if you earn up to 400 percent of poverty. Higher tax credits will be issued to applicants with lower incomes. You can choose any of the four health plan tiers on the exchange to apply your discount if you qualify, but you will be responsible for paying the difference between the subsidy and the premium of the plan they choose.



Prior to the health care law, underwriting guidelines helped decide who was approved and who was turned away according to each insurer. The underwriting process still goes on, but the information you provide will no longer prevent you from getting coverage for the same price as a healthy person in your age group. Previously, people with a mild health problem could be cornered into paying double the normal premium. Allergies were given a bit more leeway, though underwriting was specific to each carrier, varying by state, as well. Seasonal allergies and light use of medication didn’t create much of an obstacle for insurability and rate increases, though every carrier had its own policies.

If you received allergy injections, the likelihood of paying more or being declined was high. In the past, we would generally recommend Aetna for conditions, as they allowed more sick people to buy coverage than most, for an overall higher premium for every policyholder. Yet, even if a company accepted your application, they could increase your rates or issue an exclusion period, during which you would be unable to receive coverage on allergy medications or treatment for up to 12 months — 24 in some states.

The underwriting guidelines of each company would not always predict a person’s outcome until more health information and a medical history was gathered (in some cases). Therefore, it was impossible to predict whether or not a person with allergies will be turned away from a plan without a thorough assessment. This excerpt from a 2012 underwriting guide shows how one company bases their rate increases or declines for allergies. It details the large rate of acceptance for many individuals with allergies, including no premium increases. There was also a chance that an applicant could lose eligibility for undergoing testing, however.



Starting in 2010, no one under the age of 19 could be declined coverage. Therefore, if your child had allergies before the Affordable Care Act changed underwriting for adults, they could not be turned away from any health plan according to federal law. Adults would be able to enroll in a high-risk pool if they were turned down for having severe allergies prior to 2014.

Alternate Health Plans for Allergies

Although you now have the option of buying comprehensive coverage through a private insurer or an exchange, there are additional options if you aren’t finding the plan you need. If you can’t afford individual coverage, you may have the option of a public health plan, depending on your state’s income regulations. Also, your employer might offer a decent policy to you and your family.  If you or your spouse has the chance to use job-based coverage, it may be worth a look. Here are a few ideas that may be available to you depending on your life situation, employment and income.


Employer-Sponsored Insurance

If you have the option of coverage through your employer, you might consider these benefits. Some employers (especially due to the employer mandate requiring large businesses to provide coverage to full-time workers) may not offer the widest range of coverage, but other organizations such as schools and hospitals provide a better policy. Every employer can choose a different plan, and many times this determines an employee’s plan type in advance, while others give their workers a few options. Your employer pays a portion of the premiums, yet usually coverage is about the same as buying your own plan, sometimes more.

Group plans cannot decline anyone for coverage, and are supposed to offer more robust benefits under health reform. One caveat is the waiting period while your application is approved. In order to stay covered during the waiting period, buy an individual plan where you can pay month-to-month and cancel when your new benefits are effective. All individual plans provide this option. If you decide to join your employer’s health plan, you will also have the option of wellness programs to help you stay healthy.


Medicaid and CHIP

If you are unable to afford a private health plan because of your income, yet need assistance paying for allergy medications, treatments and general health care, Medicaid is a good solution. Each state has its own specifications for income and coverage, though once you are accepted and enrolled, getting your allergy medications covered should not be an issue. Medicaid usually accepts children, families, pregnant women and recipients of SSI, though a few states have opened it up to adults without children or disabilities. Check your state‘s income guidelines to see if you qualify in the Public Assistance section of your state’s subsite, or by contacting your local Department of Health and Human Services.

CHIP, the Children’s Health Insurance Program, is another option if your family income is over the Medicaid limit and you still cannot afford a private health plan. Children under age 19 will be approved for CHIP no matter what their health or income status, though subsidized coverage cuts off at 200-300 percent FPL depending on the state. Like Medicaid, the Children’s Health Insurance Program will cover any specific health needs a member has. Medicaid also has a program (Medically Needy or Spend Down) for individuals who spend a large sum of their income on health care bills, which will help you pay for them.




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Asthma & Allergy Foundation of America





1. U.S. National Library of Medicine. “Allergies”.