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Ashford Insurance

Does Medicare Cover Pre-Existing Conditions?

Picture of Sonia Ashford

Sonia Ashford

Sonia Ashford is the owner of Ashford Insurance, an independent health insurance agency specializing in Texas Medicare insurance.

A pre-existing condition is any health problem including serious illnesses like cancer, as well as chronic conditions like acne, asthma, diabetes, or heart disease you had before the scheduled start date or application for your Medicare healthcare coverage.

Does Medicare Cover Pre-Existing Conditions?

As you prepare to enroll in Medicare, you may wonder whether your preexisting condition will be covered. It’s a common concern.

Pre-existing conditions offer an additional layer of complexity. If you’ve had an injury or contracted an illness before turning 65, you may wonder how it may affect your eligibility and what options are available to you.

What are pre-existing conditions?

A pre-existing condition is any health problem including serious illnesses like cancer, as well as chronic conditions like acne, asthma, diabetes, or heart disease you had before the scheduled start date or application for your Medicare healthcare coverage.

Will Medicare eligibility be affected because of a pre-existing condition?

Also known as previous health conditions, pre-existing conditions do not negatively affect your Medicare eligibility or plan options. Medicare is not dependent on the status of your health so any existing health conditions will not affect your eligibility as long as you apply at the correct time. This applies to Medicare Part A, Part B, or Part D.

You cannot be denied Medicare coverage for pre-existing conditions if you follow the correct procedures and adhere to proper enrollment windows but could limit your ability to get a Medigap policy later.

Original Medicare, which includes Part A (hospital insurance) and Part B (medical insurance), covers preexisting conditions.

Medicare Part D (prescription drug insurance) will also cover the medications you’re currently taking for your preexisting condition.

How do I enroll in Medicare with pre-existing conditions?

If you have pre-existing conditions, you will need to submit your enrollment at a time when health questions are not required. This is referred to as the Initial Enrollment Period. It’s important to be clear on this since it only happens once in a person’s lifetime or under special circumstances. It is different for each person; it is why many people end up missing out.

What is the Initial Enrollment Period?

A Medicare Initial Enrollment Period is a window that lets newly eligible recipients enroll for Medicare coverage. It differs from person to person and is based on several factors. Generally, it is when you turn 65 years old.

Your enrollment period lasts for seven months, starting three months before you turn 65 and ending three months after the month you turn 65.

If you miss this Initial Enrollment Period, you can still enroll between January and March of each year, but you might pay a monthly late enrollment penalty if you don’t qualify for an additional special enrollment period.

There are special situations that may impede your enrollment. In cases like this, it’s best to refer to the Medicare website to receive clarity on your unique situation and how that would affect your enrollment period. You may also qualify for automatic enrollment into Medicare if you are already collecting Social Security benefits before your 65th birthday.

As a federal program and under current legislation you can enroll with no health questions. If you have pre-existing conditions, knowing your correct enrollment periods will save you additional expenses and headaches.

Does Medicare cover my pre-existing conditions?

Under the Affordable Care Act, there is no additional cost for Original Medicare coverage if you have preexisting conditions the extent of your Medicare coverage is not affected by when you contracted a condition. Conditions that were present before the start date of your Medicare coverage will still be treated within the parameters of your plan.

It’s important to keep in mind that while it covers your pre-existing conditions if it falls out of the parameters of your Medicare coverage, you will still be responsible for carrying those additional expenses on your own. This is where Medigap or Medicare supplement health insurance comes into play.

What is Medigap insurance?

A Medigap policy is health insurance that fills the “gaps” in Original Medicare Plan coverage. They help pay a portion of the health care costs that the Original Medicare Plan does not cover.

Some costs aren’t covered by Medicare Part A and Part B and a Medigap policy can help pay those expenses. Sold by private health insurance companies, Medigap policies have more limitations on preexisting conditions, which can impact your ability to get them. They are also known as Medicare Supplement Insurance.

If you are in the Original Medicare Plan and have a Medigap policy, both policies will each pay their share of covered healthcare costs. You will need to carry a Medicare Part A and Part B policy while continuing to pay the monthly premiums associated with Medicare Part B. Since it’s provided by a private insurance company, there is a premium involved with Medigap as well.

Can I enroll in Medigap with pre-existing conditions?

As is the case with Medicare, federal law prohibits private insurers from denying Medigap coverage to individuals with pre-existing conditions. However, as with Medicare, when you enroll will play a factor. You will want to note the enrollment period that does not require health questions related to pre-existing conditions.

Do Medicare Supplement Plans (Medigap Policies) Cover Preexisting Conditions?

If you sign up for a Medigap policy during your six-month Medigap Open Enrollment Period, you won’t be denied coverage and you’ll be charged the same rate as people who don’t have preexisting conditions. If you don’t sign up during your Medigap Open Enrollment Period, you can still buy coverage later, but you may face a higher cost from medical underwriting and you could even be denied coverage.

Enrolling during your Medigap Open Enrollment Period means you generally will get better prices as well as more policy choices. Even with health problems, you can purchase any Medigap policy sold in your state.

In most cases, your six-month Medigap Open Enrollment Period starts the month you turn 65 and enroll in Medicare Part B. However, if you currently have insurance through your employer or a union, your Medigap Open Enrollment Period won’t begin until you sign up for Part B.

What Is the “Preexisting Condition Waiting Period” for Medicare Supplement?

Outside of your Medigap Open Enrollment Period, the Medigap provider may impose a waiting period, meaning your out-of-pocket costs for your preexisting condition won’t be covered for up to six months. Your preexisting condition also may not be covered for six months if it was treated or diagnosed within six months before your Medigap policy starts.

If you have had at least six months of continuous health insurance, known as “creditable coverage,” before signing up for your Medigap policy, the health insurance provider can’t impose a waiting period before covering preexisting conditions. Your break in coverage can’t be more than 63 days for the previous “creditable coverage” to be eligible.

It’s also possible to avoid a waiting period if you have guaranteed issue rights — federal or state protections that mean an insurance company must sell you a Medigap policy that covers your preexisting condition without charging you a higher price.

When Do You Have a Guaranteed Issue Right?

The first time you have a guaranteed issue right is during your Medigap Open Enrollment Period. Other times when you have this right may include:

  • Your current Medicare Advantage plan is leaving Medicare or stops providing care in your area, or you move out of the plan’s service area.
  • You have both Original Medicare and an employer group plan or union coverage that pays second to Medicare is ending.
  • You have Original Medicare and a Medicare SELECT plan but you move out of the Medicare SELECT plan’s service area.
  • You joined a Medicare Advantage plan or Program of All-Inclusive Care for the Elderly (PACE) plan when you first enrolled in Medicare Part A, but, within the first year, you decide to switch to Original Medicare.
  • You dropped Medigap coverage to enroll in Medicare Advantage for the first time, but, within a year, you want to switch back.
  • Your Medigap provider goes bankrupt, leaving you without coverage, or your coverage ends through no fault of your own.
  • You drop a Medicare Advantage plan or Medigap policy because the insurance provider misled you or hasn’t adhered to Medicare rules.

Does Medicare Advantage Cover Preexisting Conditions?

Offered by private health insurance companies that contract with Medicare, Medicare Advantage (MA) plans provide the same Part A and Part B coverage available in Original Medicare. Most include prescription drug coverage through Medicare Part D. The most common types of MA plans are health maintenance organizations (HMO), preferred provider organizations (PPO), private fee-for-service (PFFS), and special needs plans (SNP).

As with Original Medicare, Medicare Advantage plans can’t charge you more for preexisting conditions. Because they are offered by private insurance companies, basic costs for Medicare Advantage plans will vary by plan. In addition, you can’t be denied coverage based on preexisting conditions.

If you have end-stage renal disease (ESRD), you’ll generally need to use Original Medicare or enroll in a Special Needs Plan.

However, there are some exceptions. If you’re currently enrolled in a Medicare Advantage health plan before being diagnosed with ESRD, you may be able to continue with that coverage or change plans. You may also be eligible if you underwent a successful kidney transplant.

Final thoughts

With a few exceptions, Medicare does cover preexisting conditions and you won’t pay more for that coverage or have to wait for the coverage to start. Even in the rare instance, you face a waiting period, you may be able to shorten or even avoid it. Overall, your preexisting conditions will not prevent you from getting Medicare but could limit your ability to get a Medigap policy.

Enrolling in Medicare with pre-existing conditions is possible. Regardless of your physical health at the time of enrollment, you cannot be denied Medicare coverage if you follow the steps outlined above.

While the entire process can seem overwhelming at first, if you know when your Medicare initial enrollment period begins and apply during that time and do the same with your Medigap policy, you will receive the same comprehensive Medicare and Medigap coverage as everyone else.

Key takeaways:

  • You cannot be denied Original Medicare coverage because of pre-existing conditions.
  • It is important to identify your Medicare initial enrollment period and apply for coverage within that window.
  • Medicare will cover your pre-existing conditions to the extent of what the plan allows.
  • You are eligible to apply for Medigap through private insurers as long as you are also carrying Medicare Part A and Part B.
  • As with Medicare, you cannot be denied coverage from Medigap because of pre-existing conditions.

 

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

 

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Picture of Sonia Ashford

Sonia Ashford

Sonia Ashford, “The Medicare Insurance Lady”, has been helping Medicare eligibles in Texas with their Medicare Insurance since 2005.