October 6, 2016
Medicare defines a pre-existing condition as any health condition or disability that you have prior to the coverage start date for a new insurance plan. If you have Original Medicare or Medicare Advantage, you are generally covered for all Medicare benefits even if you have a pre-existing condition or disability. However, if you’re enrolled in a Medicare Supplement (Medigap) plan or have end-stage renal disease (ESRD), there are some exceptions.
Pre-existing conditions and Medicare Supplement plans
Medicare Supplement (Medigap) plans are offered by private insurance companies and can help you pay for out-of-pocket costs for services covered under Medicare Part A and Part B. Different Medicare Supplement plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles. While Original Medicare doesn’t restrict coverage based on pre-existing conditions, the rules are different for Medicare supplemental insurance. Private insurers can turn down your application because of a disability or pre-existing condition if you don’t sign up during your Medigap Open Enrollment Period. There aren’t any specific pre-existing conditions not covered by Medicare Supplement plans; the health insurance company that offers the plan establishes its underwriting guidelines regarding pre-existing conditions.
A Medicare Supplement plan must accept you if you enroll during your individual Medigap Open Enrollment Period. This is the six-month period that automatically begins when you turn 65 and are enrolled in Part B. During this enrollment period, you have a one-time, guaranteed right to enroll in any Medicare Supplement plan. Private insurance companies cannot deny you coverage or charge you a higher premium due to health reasons.
If you sign up for a Medicare Supplement policy after your Medigap Open Enrollment Period ends:
- Keep in mind that even if a Medicare Supplement plan accepts your application for membership, the insurer may make you wait up to six months before covering your pre-existing condition(s). This is known as the Medigap “look-back period” or “pre-existing waiting period,” and it applies to any health conditions you were diagnosed or treated for within six months of the Medicare Supplement plan coverage start date.
- You may be subject to medical underwriting or your application for coverage declined by Medicare Supplement based on your health status. If you’ve missed this enrollment period, you may still have guaranteed issue rights in some circumstances.
End-stage renal disease
If you have end-stage renal disease (ESRD), you may not be able to buy the Medicare Supplement policy you want, or any Medigap policy, until you turn 65. Eligibility rules vary depending on the state.
Individuals with end-stage renal disease generally cannot enroll in most Medicare Advantage plans, regardless of age, however there are a few exceptions. If you have ESRD, you may be able to receive coverage from a Medicare Advantage plan if:
- You developed ESRD when you were already enrolled in a Medicare Advantage plan.
- You had a successful kidney transplant to treat your ESRD and are still eligible for Medicare coverage.
- You enroll in a Medicare Advantage plan offered by an insurer that you were previously receiving coverage from, but in a different type of plan.
- You enroll in a Medicare Special Needs Plan (SNP), a type of Medicare Advantage plan.
Pre-existing conditions and Medicare Special Needs Plans
You may be able to enroll in a Medicare Special Needs Plan (SNP) if you have a qualifying pre-existing condition. SNPs are a type of Medicare Advantage plan with benefits tailored for people with specialized needs.
One category of Special Needs Plans, the Chronic Condition SNP, is for individuals with a specific health condition. You may be eligible to enroll in a Chronic Condition SNP if you have one or more of the following:
- Alcoholism (chronic)
- Drug addiction
- Autoimmune disorder
- Disorders of the heart or blood vessels (cardiovascular system)
- Heart failure (chronic)
- End-stage liver disease
- ESRD requiring kidney dialysis
- Chronic lung disorders
- Behavioral health conditions (chronic and disabling)
- Severe hematologic disorder
If you are eligible for a Medicare Chronic Condition SNP, you can enroll at any time if a plan is available where you live. Otherwise, you can still get your Medicare coverage through Original Medicare or a Medicare Advantage plan, with the possible exception of end stage renal disease (ESRD), as noted above.
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