Can you be denied health insurance if you have herpes?

Herpes is one of the most common sexually transmitted diseases in the United States. The infection is considered a preexisting condition when applying for private health insurance coverage. Consequently, insurance providers cannot deny coverage or charge higher premiums just because you have herpes. 

The Affordable Care Act (ACA) requires insurance companies to cover all medically necessary treatment and prescription drugs for all preexisting conditions, including for STDs like herpes. Insurers must provide such coverage without prior approval. 

This article explores everything about herpes—its causes, treatment plans, costs, and insurance coverage that can help offset medical expenses.

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What is herpes? 

Herpes is a common infection caused by the herpes simplex virus (HSV). According to the Centers for Disease Control and Prevention (CDC), nearly one in every six adults aged 15-49 has the herpes virus. 

There are two main types of HSV: HSV-1 and HSV-2. The former typically causes mild symptoms and outbreaks around the mouth or nose, called cold sores or fever blisters. These sores can be very painful, especially in your mouth. 

HSV-2 tends to cause more severe symptoms, but either type of infection can affect the genitals and other parts of your body, such as your eyes or skin. Common symptoms include the following:

• Genital itching, burning, or tingling
• Flu-like symptoms such as swollen glands and fever
• Small fluid-filled blisters that can burst and become painful sores
• Pain in the legs, buttocks, or genital area

Most patients are asymptomatic, showing no physical signs of the disease. However, they can still transmit the virus. According to a 2011 study published in the Journal of the American Medical Association, the virus shed load is about 10% for asymptomatic HSV-2 infections. 

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Treatment Options and the Cost of Treatment 

The herpes simplex virus is not fatal. Prescription medications or nonprescription treatments can help reduce outbreaks and improve your quality of life. If you have herpes, talk to a doctor about whether antiviral therapy is right for you.

Here are some of the common medications used to treat herpes infections:

• Valacyclovir (Valtrex): $20 per pill or $240-$320 for a 30-day supply
• Famciclovir (Famvir): $40-$50 per pill or around $400-$450 for a 30-day supply
• Acyclovir (Zovirax): $10 or less per pill or $200-$400 for a 30-day supply

Unfortunately, medications for herpes are expensive. A 2021 study on lifetime medical costs for herpes treatment shows an average of $972 per treated case. The average expense per resurging infection is $165. Medication accounts for 60% of the total treatment cost. 

The ACA and Herpes Treatment 

Prior to 2010, insurance companies had the liberty to refuse applications from patients with preexisting conditions. The carriers would also increase premiums for diseases thought expensive to treat. The discrimination forced people to pick up costly, high-risk health insurance that significantly increased medical costs for American families. 

Under the ACA, no individual can be discriminated against when buying health insurance based on a preexisting condition like herpes. Nor can they be charged more for coverage. Insurance companies cannot deny people with herpes the benefits that help treat the disease or its symptoms.

The ACA also contains what is known as essential health benefits (EHBs), which include prescription drug coverage. People with herpes do not have to pay extra to get EHBs and prescriptions covered under their health plan. 

If you are taking prescription drugs for your herpes, you need to know if your plan covers them before enrolling. You should ask your doctor and the insurance company about the options available. 

State Law Riders 

Most states have local ordinances that allow insurers to use riders to deny coverage for individuals with a higher risk or complications such as HIV. The insurance company can have you sign on a rider, which exempts them from paying for any herpes treatment. Check with your state’s Department of Insurance for more information regarding what kind of protection is available where you live.

Short-Term Policies 

While the ACA has provided exciting prospects for affordable healthcare, most insurance policies continue to maintain unaffordable premiums for a section of the population. Short-term policies offer a safety net for individuals who find themselves temporarily without coverage or cannot afford it. 

Short-term policies typically don’t fall under the scope of ACA guidelines. These covers are medically underwritten, and insurers can deny coverage due to high-risk or preexisting conditions such as herpes. 

Because a short-term policy targets healthy individuals without any medical conditions, you should research the exclusions in each plan before deciding to purchase. The post-claims underwriting can reveal your medical history even when you choose not to disclose the full information about your herpes condition. This can lead to the insurer voiding your policy. 

Coverage for Herpes Treatment When Pregnant

Genital herpes can cause fatal infections in neonates, and mothers with herpes infections require urgent care. If you have private health insurance, your insurance must cover all the necessary treatment for genital herpes during pregnancy. 

The Affordable Care Act also requires that Medicaid cover all treatment for genital herpes during pregnancy. If you have an outbreak and are pregnant or planning to become pregnant, talk to your doctor as soon as possible. 

Doctors usually prescribe an antiviral drug (Acyclovir) to treat the first episode of herpes. They may prescribe this drug daily in the last few weeks of your pregnancy if you’ve had a history of recurrent outbreaks. Your doctor will also likely recommend a cesarean section when it’s time to deliver so that your baby will not be exposed to the infection during delivery.

Read more: How much does urgent care cost without health insurance?

Preexisting Conditions Disclosures 

Can health insurance companies deny coverage if you do not disclose your health status? The short answer is no. The Affordable Care Act bars insurance companies from using information about past infections for your eligibility analysis. 

The carrier may ask for additional information about your herpes infection, the last time you had an outbreak, and its severity. However, under the ACA, you do not have to provide the answer if the insurer doesn’t directly ask if you’ve had an STD. 

If explicitly asked, you need to answer truthfully. Hiding any information about the sexually transmitted infection can void the policy if the insurer later discovers your lie. Insurance companies will do their research regarding their client, including looking through medical records.

They will also search through your claims and pharmacy history. They can also use data from other sources such as credit reports, motor vehicle reports, and prescription drug monitoring programs. If the insurance company finds out about a preexisting condition and is not informed about it, they can deny coverage.

There is a good chance that they will block coverage for all preexisting conditions, not only herpes, or even cancel the policy entirely. You can avoid damaging your health coverage by being truthful in your disclosures. 

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Case Studies: Can you be denied health insurance if you have herpes?

Case Study 1: Jennifer’s Struggle for Coverage

Jennifer, a 32-year-old woman, faced rejections from multiple insurers when applying for health insurance due to her herpes diagnosis, despite being in good health and leading a responsible lifestyle. Her condition became a major obstacle in her pursuit of comprehensive health coverage.

Case Study 2: John’s Successful Application

John, a 40-year-old man with herpes, overcame hurdles by researching and choosing an insurance provider that covered pre-existing conditions, allowing him to secure health insurance successfully. His diligent approach and commitment to managing his condition enabled him to successfully navigate the insurance application process by providing detailed information.

Case Study 3: Sarah’s Limited Options

Sarah, a 27-year-old college graduate, faced challenges when searching for a job as many employers provided health insurance plans that didn’t cover pre-existing conditions like her herpes diagnosis. Sarah had to decide whether to accept a job with limited or no health insurance or keep searching for a position with comprehensive coverage to meet her medical needs.

Case Study 4: Mark’s Coverage Denial

Mark, a 45-year-old man with herpes, applied for health insurance through his employer’s group plan. However, his application was denied due to the insurer’s policy of excluding coverage for pre-existing conditions for a specified period. Mark had to either seek alternative insurance options or bear the financial burden of paying for his medical expenses out-of-pocket.

Case Study 5: Lisa’s Advocacy Efforts

Lisa, a 36-year-old woman, directly contacted insurance companies, openly discussing her herpes diagnosis and emphasizing her responsible healthcare management to secure health insurance coverage. Lisa’s persistent advocacy paid off as she found an insurance provider willing to offer her coverage, emphasizing the value of proactive communication and seeking supportive insurers.

The Bottom Line: Health Insurance Coverage for Herpes

The Affordable Care Act protects consumers against being denied coverage due to their past medical history. It’s illegal for carriers to use preexisting conditions such as herpes as a factor when assessing eligibility. 

Local state laws and short-term policies can exempt insurers from the ACA guidelines, allowing them to deny eligibility for the herpes infection. If you are searching for new health insurance coverage, it’s important to disclose your health status to the insurance company. False information on your application can lead to claim denials. 

Do not let embarrassment or fear stop you from finding adequate heath insurance coverage. Use an insurance quote tool right now to look for an affordable policy. Online rate quotesare ready the moment your enter your zip code, so do it now!

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