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Does Medicare Cover Pre-existing Conditions?

Yes, Medicare covers pre-existing conditions. People who may be eligible for Medicare at 65 can’t be denied coverage or charged more based on their health conditions. Plus, people younger than 65 and with certain disabilities or health conditions may be eligible for Medicare coverage early.

Medicare’s coverage of pre-existing conditions may appeal to older adults who are facing the possibility of age-related health issues. The risk of many health conditions, from arthritis to diabetes to cancer, increases with age. Developing one or more of these conditions before reaching the standard age for Medicare (65) doesn’t affect eligibility.

For people younger than 65, not only does Medicare cover pre-existing conditions, but having a serious medical condition is a prerequisite for getting coverage. People under 65 are eligible for Medicare if they have end-stage renal disease, ALS, or receive Social Security Disability Insurance (SSDI) benefits.

As of 2018 (the most recent data available), the most common Medicare pre-existing conditions among beneficiaries of all ages are arthritis, chronic kidney disease, diabetes, high cholesterol, and high blood pressure. Enrollees who are living with two or more serious conditions may receive chronic care management services from Medicare.

Are Pre-existing and Chronic Conditions Different? 

In short, no. There’s a lot of overlap between pre-existing conditions and chronic conditions, and the two terms are often used interchangeably. The difference is that “pre-existing condition” is an insurance term, while “chronic condition” is a medical term.

In the insurance world, a pre-existing condition is any health condition a person had before they applied for or enrolled in a new health insurance policy. In the medical world, a chronic condition is any health condition that lasts for a year or more and either limits your daily activities or requires ongoing medical care.

Often, pre-existing conditions are also chronic conditions. The specific diagnoses that count as a pre-existing condition vary between insurers but generally range from relatively mild ailments, such as eczema or seasonal allergies, to more serious health problems, such as diabetes, cancer, or heart disease.

In some situations, insurers classify non-chronic health conditions as pre-existing conditions. This could include diagnoses or treatments an applicant has received in the past. Whether your health issue is new, resolved, or chronic, you may wonder how pre-existing conditions and Medicare work.

Does Medicare Advantage Cover Pre-existing Conditions? 

Yes, Medicare Advantage plans cover pre-existing conditions. Private insurance companies sell these plans, and like traditional Medicare, they’re available to people with pre-existing conditions. However, Medicare Advantage pre-existing conditions coverage may not be the right option for people with chronic health needs.

People with pre-existing health conditions may be drawn to Medicare Advantage plans for their coverage of supplemental benefits that aren’t available in Original Medicare. The vast majority of plans for sale in 2023 cover vision, hearing, and dental care. Other common benefits include over-the-counter drugs, transportation assistance, and meal delivery.

Before joining a Medicare Advantage plan, people with chronic health needs should be aware that these plans are allowed to impose different rules for accessing care than Original Medicare. They may charge higher copayments for certain care, require referrals or pre-authorizations before covering health services, or limit coverage to in-network doctors and specialists.

With these requirements, people with chronic conditions may pay more for the care they receive. Costs vary based on the plan, but according to a 2022 analysis, 77% of people with Medicare Advantage would pay more for a 14-day hospital stay than people with traditional Medicare. Work with a trusted agent to estimate the costs of Medicare Advantage pre-existing conditions coverage.

Does Medicare Supplement Insurance Cover Pre-existing Conditions?

Yes, Medicare Supplement Insurance, also known as Medigap, helps cover out-of-pocket costs in Original Medicare, such as coinsurance and deductibles. This supplemental coverage is available to people with pre-existing conditions so long as they sign up during their Medigap Open Enrollment Period.

Original Medicare doesn’t limit beneficiaries’ out-of-pocket expenses; for people with pre-existing conditions, the costs of coinsurance and copayments can add up. Medigap plans can help reduce these costs. In 2019, Medicare beneficiaries with Medigap were three times less likely to experience difficulty paying medical bills.

Under federal law, the Medigap Open Enrollment Period is a 6-month window that begins when a person is both 65 years old and enrolled in Medicare Part B. During this period; Medicare members have the right to buy any Medigap policy for sale in their state. Insurers cannot deny coverage or charge more based on applicants’ pre-existing conditions.

Outside the Medigap Open Enrollment Period, insurers are allowed to use medical underwriting during the application process. That means they can refuse to sell Medigap policies to people with pre-existing conditions or charge higher premiums based on applicants’ pre-existing conditions. If you’re interested in Medigap, mark your enrollment window on your calendar.

Some states offer additional Medigap protections for people with pre-existing conditions. In some states, including Wisconsin, an Open Enrollment Period is available to people under 65. Other states, including New York, offer year-round open enrollment. Contact your state Department of Insurance for details about when you can enroll in Medigap with a pre-existing condition.

What Pre-existing Conditions Are Not Covered By Medicare?

In limited situations, Medicare doesn’t cover pre-existing conditions. People eligible for Medicare due to a disability or end-stage renal disease typically have a waiting period before coverage begins. Beneficiaries with pre-existing conditions may have a waiting period when they sign up for Medigap.

People younger than 65 who receive SSDI generally have a 24-month waiting period for Medicare. They’re automatically enrolled into Medicare when they receive their 25th month of SSDI benefits. However, past periods of disability can be used to shorten this waiting period in some situations. There’s no waiting period for people with Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease).

Waiting periods may apply to people who are eligible for Medicare based on end-stage renal disease. People who are on dialysis typically have a 4-month waiting period, but eligible enrollees can shorten this period by participating in a home dialysis training program. 

When people with health issues sign up for Medigap, insurers can enforce a 6-month pre-existing condition waiting period. During this time, Medigap doesn’t help with out-of-pocket costs related to the pre-existing condition — but Original Medicare still covers its share. This waiting period may be waived if you buy Medigap to replace previous health insurance coverage.

During the waiting period for Medicare coverage, consider other sources of health insurance. People who are waiting for their Medicare coverage to begin could enroll in Medicaid if they meet their state’s eligibility requirements. An employer-sponsored plan is another potential source of coverage.

Should You Get a Medicare Advantage Special Needs Plan?

Special Needs Plans are Medicare Advantage plans that serve people with specific health conditions or care needs. These plans customize their covered benefits and provider networks to suit their members’ needs. Before joining a Special Needs Plan, there are both advantages and disadvantages to consider. 

There are three types of Special Needs Plans, and each limits enrollment to a specific group of Medicare beneficiaries. People with pre-existing conditions could be eligible for one or more of these plan types:

  • Chronic Condition Special Needs Plans (C-SNP): These plans are open to Medicare beneficiaries with specific severe or disabling pre-existing conditions. For example, there are C-SNPs for people with diabetes, end-stage renal disease, heart failure, and other conditions.
  • Dual-Eligible Special Needs Plans (D-SNP): These plans are for Medicare beneficiaries who also have Medicaid.
  • Institutional Special Needs Plans (I-SNP): These plans are available to Medicare beneficiaries who live in a nursing home or other long-term care setting or who need the level of care provided by those facilities.

These plans tailor their benefits to better suit the needs of their members. For example, a C-SNP for people with chronic lung disorders may give members access to lung specialists and breathing treatments. In contrast, a C-SNP for people with diabetes may cover tailored benefits such as insulin management and nutritional training.

Eligibility Criteria

People who fall into 1 of the three categories described above may be eligible to join a Special Needs Plan if they’re enrolled in both Medicare Part A and Part B and live in the plan’s service area. Special Needs Plans may not be available in some areas, but where they’re offered, the service area may be limited to certain counties or states.

Medicare beneficiaries can stay enrolled in a Special Needs Plan for as long as they meet the plan’s eligibility requirements. Losing eligibility triggers a Special Enrollment Period, allowing beneficiaries to sign up for a different plan mid-year. Plans must provide a grace period of at least one month to give members time to replace their coverage.

Putting It All Together

Most Medicare-eligible individuals will be happy to find out that treatment for their medical issue is most likely covered within standard guidelines by the program. However, make sure to keep in mind that this is not monolithic. Certain regulations, particularly those that pertain to Medigap, may govern when and if coverage is available. If you’re having trouble choosing between two plans or are curious about which option may work best for you, make sure to enlist the services of a trusted agent to help you navigate the process.

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