Medicare and Pre-Existing Conditions
Depending on when you apply and the guaranteed issue rights in your state, you may be concerned that pre-existing conditions may impact your ability to purchase specific Medicare insurance plans. However, pre-existing medical conditions do not jeopardize your eligibility for Original Medicare benefits as long as you apply during the correct enrollment period.
Does Medicare Cover Pre-Existing Conditions?
If you are over 65, then yes. The federal Medicare program provides health care insurance to people 65 and older regardless of health status. Therefore, pre-existing medical conditions do not impact eligibility or pricing. In addition, by signing up for Original Medicare, when you become eligible, you avoid a late enrollment penalty.
Does Medicare cover people younger than 65 with pre-existing conditions?
People younger than 65 with a qualifying disability are automatically enrolled in Medicare after receiving 24 months of disability benefits from the Social Security Administration (SSA) or the Railroad Retirement Board (RRB). In the case of amyotrophic lateral sclerosis (Lou Gehrig’s disease), automatic enrollment is effective the month you begin receiving Social Security disability benefits. You must initiate enrollment if you have end-stage renal disease (ESRD).
Do Medicare Supplement Plans Cover Pre-Existing Conditions?
You can apply for a Medicare Supplement plan (Medigap) during a six-month window that begins six months from the first month you turn 65 or older. This time frame is known as the Medigap Open Enrollment Period, and applying within this window guarantees that your pre-existing conditions will be covered from the policy’s start date.
It also guarantees your right to:
- Purchase any Medigap policy available in your area
- Pay the same premium for the same Medigap policy as people who do not have pre-existing health conditions
However, applications received after the Medigap Open Enrollment Period are subject to medical underwriting. Underwriters evaluate risk and determine the price.
Based on their assessment, insurance companies can:
- Deny coverage
- Cover pre-existing conditions but charge a higher premium to compensate for the risk
- Cover pre-existing conditions but require a six-month waiting period before coverage starts
Waiting Period for Pre-Existing Conditions on a Medigap Plan
If you apply for a Medigap plan outside of your Medigap Open Enrollment Period and don’t have creditable coverage, the insurer can impose a 6-month waiting period for coverage of pre-existing conditions. During this time, the plan can delay coverage for healthcare related to conditions you were diagnosed with or treated for in the 6 months before your Medigap policy started.
You can skip the pre-existing condition waiting period if either of these applies:
- You apply during your 6-month Medigap Open Enrollment Period, which begins the month you’re both 65 or older and enrolled in Medicare Part B.
- You have “creditable coverage” — that is, prior health insurance (such as group coverage or another Medicare plan) without a gap of more than 63 days before your Medigap coverage begins.
Do Medicare Advantage Plans Cover Pre-Existing Conditions?
Yes, pre-existing conditions are covered by Medicare Advantage plans. You cannot be denied coverage or charged more because of pre-existing conditions. However, a Medicare Supplement (Medigap) plan better protects those with chronic conditions.
Special Needs Plan
A Special Needs Plan (SNP) is a type of Medicare Advantage plan that provides medical insurance to people with chronic conditions who reside in nursing homes or receive both Medicare and Medicaid Services. SNPs tailor benefits, provider options, and formularies to align with these groups.
Switching Plans
When you first enroll in Original Medicare (Parts A and B) and choose to try a Medicare Advantage (Part C) plan, you’re given a special protection called a trial right. This trial right gives you up to 12 months to decide if you want to stay with the Medicare Advantage plan or switch back to Original Medicare. If you decide that the Medicare Advantage plan isn’t the right fit for you — for any reason — you have the right to return to Original Medicare and buy a Medicare Supplement Insurance plan, also known as Medigap.
This trial right is one of your guaranteed issue rights. These rights protect you from being denied a Medigap policy due to your health history. With guaranteed issue rights, insurance companies are required by law to sell you a Medigap plan, even if you have pre-existing health conditions. They also can’t charge you higher premiums than they would charge someone in good health. This means you can get coverage without undergoing medical underwriting, which would normally look at your past and current health conditions.
It’s important to note that this 12-month period starts the day your Medicare Advantage coverage begins — not when you enrolled in Medicare itself.
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