Is menopause a pre-existing condition?

Q. I may have to change insurance companies soon, and I will also likely enter menopause. Will my new insurer consider that a pre-existing condition?

A. Any middle-aged person contemplating a switch in health insurance plans has every reason to be concerned about pre-existing conditions. But menopause itself isn't one of them because it's not a disease, it's a normal stage of life for women.

"Just being a 50-year-old woman with no symptoms obviously would not be a problem," says Mark Brown, a certified financial planner and longtime insurance agent in Naperville, Ill.

But menopause can produce symptoms for which women do seek medical treatment—hot flashes, say, or trouble sleeping. In most states, Brown said, those might well trigger a rate hike or be exempt from coverage for a period of time or even indefinitely.

But before we go any further, it's important to make clear that any pre-existing conditions you have won't affect you if you are simply switching from one employee group plan to another. So long as you have been continuously covered for a year and avoid a break in coverage of more than 63 days, your new group plan can't turn you down, charge you extra, or exclude your condition from coverage. Those rights are guaranteed under a federal law called HIPAA.

The same doesn't hold true, however, if you get insurance on your own. In that case, any ailment that so much as hints at a future cost for the insurer can be held against you. For example, underwriting guidelines for one company note that menopausal symptoms controlled with hormone replacement therapy will not trigger special treatment, but a woman with uncontrolled symptoms must agree to a rider excluding either that condition or the entire reproductive system from coverage.

Each state has its own rules for how far back insurers can look for pre-existing conditions and how much they can raise rates based on health status, with some offering a lot more consumer protection than others. For an excellent state-by-state breakdown of rules in the individual market, go to the Kaiser Family Foundation's State Health Facts site.

In general, though, here's how it works. Insurers have lists of conditions—ranging from major depression to diabetes to a history of cancer—that trigger automatic rejection of a candidate. Taking certain medications or working in a particular job, say firefighting or entertainment, might also trigger rejection. Risks not serious enough to lead to an automatic "no" can result in premium hikes, higher deductibles, or temporary or permanent exclusion of a condition or whole body system from coverage, if state law allows.

Insurer practices may vary. For example, one company's guidelines say that a diagnosis of osteoporosis will trigger automatic rejection, while another says mild osteoporosis should boost a woman's premium by 25 percent.

Odds are that as a person of menopausal age, you'll have some health history or ailment that could bedevil your search for an affordable plan in the individual market. Indeed, according to a report on preexisting conditions by the federal government, three quarters of Americans age 45 to 54, and a whopping 86 percent of those aged 55 to 64, have a condition that would trigger an exclusion or extra charge in the individual market. Nearly half those in the older group have a health problem that makes them uninsurable in that market.

Ready for a little good news? Under the Affordable Care Act, all this is set to change. Starting in 2014, insurers in the individual market will have to accept everyone and can't raise your premiums or exclude any part of you from coverage on account of pre-existing conditions.

Read more of our coverage of health insurance.

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—Nancy Metcalf