Does Medicare Cover Preexisting Conditions

Pre-existing conditions may impact your ability to purchase specific Medicare insurance plans, depending on when you apply and the guaranteed issue rights in your state.

The U.S. Department of Health & Human Services (HHS) defines a pre-existing condition as “a health problem you had before the date that new health coverage starts.” Pre-existing medical conditions do not jeopardize your eligibility for Original Medicare benefits but can make a difference if you are applying for Medicare Supplement Insurance.

Medicare and Pre-Existing Conditions

The federal Medicare program provides health care insurance to people 65 and older regardless of health status. By signing up for Original Medicare when you become eligible, you avoid a late enrollment penalty. Medicare Part B and Medicare Part D late enrollment fees can be attached to premiums for the duration of your coverage. Health conditions do not impact eligibility or pricing.

How does Medicare enrollment work for people younger than 65 years of age?

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 need to initiate enrollment if you have end-stage renal disease (ESRD).

Do Medicare Supplement Plans Cover Pre-Existing Conditions?

A Medigap policy is the health insurance plan for beneficiaries who want to minimize out-of-pocket costs (coinsurance, copays, deductibles). You can apply for Medigap during a six-month window that begins six months from the first of the month that you turn 65 or older. This time frame is known as the Medigap Open Enrollment Period, and applying within this window 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
  • Get coverage for pre-existing conditions from the start date of the policy

Applications received after the Medigap Open Enrollment Period are subject to medical underwriting. Underwriters evaluate risk and determine to 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

Do Medicare Advantage Plans Cover Pre-Existing Conditions?

Medicare Advantage (MA) is an alternative way to get your Medicare coverage. MA plans are available for purchase from Medicare-approved insurance companies. You can sign up for a Medicare Advantage plan even if you have pre-existing health conditions, but joining or leaving an MA plan is restricted to specific times of the year:

  • Initial Enrollment Period: when you initially become eligible for Medicare
  • General Enrollment Period: January 1 to March 31 if you have Medicare Part A and are getting Medicare Part B for the first time
  • Medicare Advantage Open Enrollment Period: January 1 to March 31 for existing MA plan members who want to switch to a different MA plan or drop their MA plan
  • Open Enrollment Period: October 15 to December 7, when you can join, switch or leave an MA plan

In addition to these standard enrollment periods, some beneficiaries are eligible for a Special Enrollment Period based on qualifying events or an MA plan’s star rating. The plan will cover pre-existing health conditions regardless of the time you sign up for MA.

How does Medicare cover chronic conditions?

A Special Needs Plan (SNP) is a type of MA 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 from Medicare Advantage to a Medigap Plan with Pre-Existing Conditions

When you register for Original Medicare and sign up for Medicare Advantage, you are given a trial right. This means that you have 12 months to return to Original Medicare and sign up for a Medigap plan. A trial right is one of the guaranteed issue rights.

When you have guaranteed issue rights (Medigap protections), private insurance companies must sell you a Medicare Supplement Insurance plan. This plan must cover all pre-existing health conditions and charge you the same as someone with no pre-existing conditions. Check with a licensed insurance agent to learn more about guaranteed issue rights in your state.