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.

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 enroll in Original Medicare and sign up for Medicare Advantage, you are given a trial right. 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.

Ready to Learn More?

Choosing the right Medicare Plan is not a decision that should be taken lightly. With Policy Guide’s assistance, you will have access to the knowledge and expertise of professional agents who can help you compare different health plans, quotes, and policies to ensure that you make an informed decision. Let us guide you through this process, so that your chosen plan best suits your needs.

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Mark Prip

Since 2003, Mark Prip has been leading  Policy Guide, Inc., providing knowledgeable information about Medicare, life insurance, and dental coverage to clients in over forty states. With his unparalleled hands-on experience aiding countless Medicare beneficiaries in selecting an appropriate health plan, he is a prime example amongst other competitors for expertise and assistance. Mark has held his Florida Health & Life Insurance License (E051889) since 2003. View his license profile on the Florida Department of Insurance website.