Does Medicare cover pre-existing conditions?

Pre-existing conditions and Medicare | Can Medicare deny pre-existing conditions? | Medigaps and pre-existing conditions | Part C and pre-existing conditions | Waiting period | How to choose the best plan

Pre-existing conditions are a term that many Americans grew up concerned about. Years ago if you had an existing health condition it was possible for an insurance company to exclude it from coverage. Fortunately, for most insurance options this practice was made illegal by the Affordable Care Act.

If you have a pre-existing health condition you can’t be denied coverage by Original Medicare or a Medicare Advantage Plan. Medicare Supplement plans (Medigaps) can still deny coverage or have pre-existing clauses which could delay enrollment.

Does Medicare cover pre-existing conditions?

Medicare doesn’t place any limitations or conditions on people with pre-existing conditions. This is consistent across all four parts of Medicare. Regardless of whether you decide to enroll in Original Medicare Part A or Part B, Medicare Part D prescription drug coverage, or a Medicare Part C all-in-one plan, pre-existing conditions will not affect your eligibility for Medicare coverage.

What’s covered

Many Medicare beneficiaries suffer from chronic health conditions that require specialized treatment. Since Medicare can’t deny coverage or exclude pre-existing conditions, these beneficiaries can typically access the treatment they need. However, some health conditions have multiple treatment options and some treatment options may not be covered by Medicare or may require prior authorization.

For treatments to be covered by Medicare, they can’t be considered experimental, and must be approved by the FDA.

What’s not covered

As mentioned above Medicare will treat and cover pre-existing conditions. However, enrolling in a Medicare Supplement Plan as secondary coverage is another story. Medigap plans require underwriting in many cases and will deny or delay coverage for certain health conditions.

Health Conditions that a Medigap plan could typically decline are:

• Chronic Obstructive Pulmonary Disorder (COPD)
• Internal Cancer – Some carriers will accept you if you’ve been cancer-free for more than two years
• Diabetes with complications – Some carriers will decline insulin usage, others will decline if you have additional health conditions such as heart complications or neuropathy
• Artirial fibrillation (AFIB)
• Heart failure

All Medigap health insurance companies have different underwriting processes and requirements. Some are more lenient on what they will approve of than others.

Some will approve you but if you have a gap in coverage they could exclude pre-existing health conditions for a period of time. This will vary from company to company. For example, Mutual of Omaha doesn‘t restrict pre-existing clauses once you‘re approved for coverage. If you have had continuous creditable coverage, the pre-existing clauses will not apply.

Can Medicare deny pre-existing conditions?

Original Medicare, Medicare Part D, and Medicare Advantage plans are not allowed to deny coverage for any pre-existing medical conditions. If you feel like Medicare has denied you coverage based on a pre-existing condition you can file an appeal or reconsideration. The process is outlined on Medicare’s website medicare.gov.

Does Medicare Supplemental insurance cover pre-existing conditions?

Medicare Supplemental insurance is a secondary wrap-around coverage option for Original Medicare. These plans require that you are first enrolled in Medicare Part A and Medicare Part B.

Because you must have Medicare insurance to enroll in these plans, they’re allowed to require medical underwriting as a condition of purchasing a policy. Medicare Supplements can deny coverage and place restrictions on pre-existing conditions. The policies will vary depending on the insurance company that you are applying for an insurance plan.

You’re not always subject to medical underwriting or pre-existing condition clauses. There are times when you can enroll in a Medigap insurance plan and these don’t apply.

When you’re turning 65 or your Medicare Part B is starting, you’re afforded an open enrollment period. During this time you can enroll in any plan offered by any company without the need for underwriting or pre-existing condition concerns.

After this period is over you’ll be subject to these items if you were to change plans. There are some exceptions. There are seven guaranteed issue situations that could apply depending on your life situation. Some states also have additional guaranteed issue rights and open enrollment rules.

In short, if you have chronic conditions and you want to enroll in a Medicare Supplement insurance policy, you should do it during your initial enrollment period.

Does Medicare Advantage cover pre-existing conditions?

Medicare Advantage plans are another way to receive your Original Medicare benefits. These private plans are sometimes referred to as Medicare Part C. Medicare Advantage plans are required to accept you and cover all health conditions covered by Medicare.

Having health conditions should never affect your enrolling or changing to another Medicare Advantage plan.

What is the usual pre-existing conditions waiting period under Medicare?

Pre-existing condition waiting periods don‘t apply to Original Medicare, Medicare Advantage Plans, or Part D prescription coverage. If enrolling in a Medicare Supplement insurance plan, most carriers will have a six-month waiting period. As mentioned above this will vary from company to company.

Typically these waiting periods don‘t apply during the guaranteed issue and open enrollment periods. You should look at the company plan materials for information on the waiting period policy.

How to choose the best Medicare plan for pre-existing conditions

The best plan is a relative term because all Medicare beneficiaries have different needs. For Original Medicare, Medicare Parts A and B, pre-existing conditions do not matter. Your coverage is guaranteed and without restrictions based on health conditions. The same goes for Medicare Advantage.

If you have chronic health conditions or pre-existing health concerns you’ll probably want to steer more towards a Medicare Advantage plan or Original Medicare with a Medigap. Original Medicare has no cap on beneficiary out-of-pocket expenses.

You can check the Medicare Advantage plans in your area to see if they have a chronic needs plan that is designed for your health condition. These types of Medicare Part C plans can have additional coverage available catered to your health needs.

Medicare Supplements are a great option if you think you will need to see health care providers often. While they can be more expensive than Medicare Advantage plans, they have the most comprehensive coverage for your healthcare needs. Remember you do have to pass medical underwriting in order to enroll in these plans.

The best time to enroll in a Medicare Supplement if you have pre-existing conditions is when you are first eligible for Medicare during your Medigap Open Enrollment Period. This way the pre-existing condition has no effect on your policy.

No matter which health coverage you choose, Medicare Advantage plans, or Original Medicare with a Medigap policy, they will give you more protection than if you enroll in Original Medicare alone. Medicare Advantage plans include drug coverage in many cases and are less expensive. Original Medicare with Medicare Supplement insurance is more expensive and for drug coverage, you’ll need to purchase a standalone Medicare Part D prescription drug plan to go along with it.