As you prepare to enroll in Medicare, you may wonder whether your preexisting condition will be covered. It’s a common concern. According to the U.S. Department of Health and Human Services, up to 50% of non-elderly Americans have some type of preexisting health condition.1
What Are Preexisting Conditions?
Preexisting conditions include serious illnesses like cancer as well as chronic conditions, like diabetes, asthma, heart disease or epilepsy. Among Americans ages 55 to 64, 48 to 86% have some kind of preexisting condition.2 Under the Affordable Care Act, you can’t be refused health insurance coverage, because you have preexisting conditions.3
Does Medicare Cover Preexisting Conditions?
Under the Affordable Care Act, there is no additional cost for Original Medicare coverage if you have preexisting conditions. Premium costs for Medicare in 2020 range from $0 to $458 per month for Part A and $144.60 for the standard Part B premium.4 Most people will qualify for the $0 premium for Part A, while most beneficiaries pay the standard Part B premium.
Medicare is divided into separate parts that work together to provide comprehensive health insurance coverage.
- Part A: Known as hospital insurance, this Medicare coverage is for inpatient hospital stays, skilled nursing facility care, some home health care services and hospice care.
- Part B: This is medical insurance that covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
- Part D: This adds prescription drug coverage to Part A and Part B (known as Original Medicare), as well as certain Medicare cost plans and Medicare Advantage plans.5
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 organization (HMO), preferred provider organization (PPO), private fee-for-service (PFFS), and special needs plans (SNP).6
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 MA plans will vary by plan.7 In addition, you can’t be denied MA 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.8
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.9
Do Medicare Supplement Plans (Medigap Policies) Cover Preexisting Conditions?
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 a Medigap policy.
For example, 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.10
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.11
What Is the “Preexisting Condition Waiting Period” for Medicare Supplement?
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.12
That being said, 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 the 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.13
It’s also possible to avoid a waiting period if you have guaranteed issue rights — federal or state protections that mean an insurance company has to 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 include:14
- 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.
With 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. All in all, your preexisting conditions will not prevent you from getting Medicare but could limit your ability to get a Medigap policy.