A pre-existing health condition is any illness, injury, disease, medical or mental condition, that is already known to exist prior to the writing and signing of an insurance contract.
Whether the individual is currently suffering from the specific ailment or they are asymptomatic (showing no evidence of any sickness or disease), is irrelevant to an acceptance or denial determination with the insurance carrier.
Pre-existing medical conditions are always a concern for anyone looking to purchase a new insurance policy. Luckily for seniors, Traditional Medicare automatically allows for enrollment as eligibility isn’t dependent on the status of your current health.
This means any pre-existing health conditions will not factor into eligibility for Medicare Part A or Medicare Part B.
The same cannot be said for Medicare Advantage Plans and some of the Medicare Supplement Plans, as there are conditions associated with pre-existing health issues, especially End Stage Renal Disease.
Pre-Existing Conditions Not Covered by Medicare
Original Medicare consists of two parts, Medicare Part A and Medicare Part B.
Medicare Part A benefits include coverage for the following:
- Any hospitalization costs
- Home health care
- Skilled nursing facility services
- Hospice care
Medicare Part B is for outpatient services which include coverage for the following:
- Any doctor’s office visits
- Preventative services
- Lab work
- Diagnostic imaging and testing
- Durable medical equipment
- Orthotics and prosthetics
- Ambulance services
- ER visits
With Traditional Medicare, you’re eligible for enrollment after turning 65. You also have the option of
enrolling in a Medicare Supplement Plan.
Medicare Supplement Plans are composed of 10 different letter plans that work alongside the
Traditional Medicare benefits.
Medicare Supplement Plans provide coverage for deductibles,
copayments, coinsurance and other medical costs that aren’t normally covered with Traditional
With Medicare Supplement Plans, there is a timeframe in which the individual is guaranteed coverage.
Purchasing the plan during the Open Enrollment Period (OEP), which is a six-month timeframe after
turning 65, you’re automatically eligible for coverage if you’re already enrolled in Medicare Part B.
During this period, you’re granted what is called the Guaranteed Issue (GI) right. With the GI right, the private insurance companies that offer Medicare Supplement Plans are required to provide your health insurance, regardless of any pre-existing health conditions.
Failing to enroll during the OEP subjects’ seniors to the underwriting process. With the underwriting
process, the individual insurance carriers can outright deny you coverage or increase the monthly
premiums based on any underlying health issues.
Medicare Advantage Plans & Pre-Existing Conditions
With Medicare and Medicare Supplement Plans, there are no specific pre-existing health conditions that will be denied coverage.
There are however, restrictions regarding individuals suffering from End Stage Renal Disease (ESRD) for those trying to obtain a Medicare Advantage Plan.
Medicare Advantage Plans are also sold by the local private insurance companies. Different from
Medicare Supplement Plans, Advantage Plans are purchased to take over coverage for Traditional
Medicare Parts A and B.
Oftentimes, this is why Medicare Advantage Plans are called Medicare Replacement Plans.
With these specific types of plans, those with ESRD are typically not eligible to enroll in any of these plans unless you fall under the exceptions of:
- You currently were enrolled in a Medicare Advantage Plan at the time of being diagnosed of End Stage Renal Disease.
- If you currently are enrolled in health care coverage through your employer and that specific insurance company also provides Medicare Advantage Plans.
- You were already enrolled in a Medicare Advantage Plan that is no longer offered. You’re able to do a one-time change and enroll in a different Medicare Advantage Plan in your area.
- You’ve had a successful kidney transplant, thus resolving your ESRD, while still be eligible for a Medicare Advantage Plan.
- You’re eligible for Medicare through a Special Needs Plan (SNP), which is a type of Medicare Advantage Plan.
Special Needs Plans & Pre-Existing Conditions
Special Needs Plan are a form of a Medicare Advantage Plan with the added benefit of including Medicare Part D.
Medicare Part D is a stand-alone Prescription Drug Plan offered through the individual insurance companies.
This plan provides prescription medication coverage which is otherwise not included in either of the Traditional Medicare Plans or any of the Medicare Supplement or Medicare Advantage Plans.
The Special Needs Plan combines Medicare Parts A, B and D, but is only eligible for individuals suffering from certain health conditions.
Additionally, the ill individual must also be eligible for both Medicare and Medicaid and/or currently residing in a long-term care facility.
Special Needs Plans provide extra healthcare benefits to help manage your individual health condition(s).
Occasionally, these types of plans may offer extra benefits, tailored for the individual’s health care needs.
These extra benefits include:
- Routine dental
- Routine vision
- Routine hearing care
- Non-emergent health care transportation to and from office visits
- Over-the-counter medication assistance
- Fitness programs
There are a variety of SNP’s and there is a specific type of plan for those individuals with chronic, pre-existing conditions.
Specific requirements for this plan include:
- Location, you must live in the area of where the SNP is available.
- You must be currently enrolled in Medicare Part A and Medicare Part B, whether it’s due to age or a disability.
- Residency in certain institutions such as a skilled nursing facility, intermediate care facility or Assisted Living Facility (ALF).
Eligibility for those individuals with special needs, due to a severe or disabling condition, must fall into the category of one or more of the following 15 chronic conditions:
- Autoimmune Disorders (Rheumatoid Arthritis, Lupus, Celiac Disease)
- Chronic alcoholism and drug dependence
- Chronic cardiovascular disease
- Chronic heart failure
- Chronic lung disorders (Asthma, COPD, Emphysema, Pulmonary Hypertension)
- Diabetes Mellitus
- End stage liver disease
- End Stage Renal Disease (ESRD) requiring dialysis
- Hematological disorders (deep vein thrombosis or DVT’s, Sickle Cell
- Anemia, Thrombocytopenia)
- Neurological disorders (Epilepsy, Multiple Sclerosis, Parkinson’s Disease, ALS)
- Certain, disabling behavioral health conditions
Once you’re declared as eligible, individuals with the above chronic conditions can enroll at any time if a local plan is available.
If your situation changes and you no longer qualify, you’ll have to go through the Special Election Period (period of time outside of the Initial Enrollment Period and the Annual Election Period in which you can enroll for the Special Needs Plan or make coverage changes).
Extra Help for Seniors with Medicare
If you have questions about pre-existing medical conditions and how they can affect insurance coverage, we can help. We specialize in senior healthcare.
Our personal mission is to help you achieve the best possible health insurance benefits regardless of current health status.
We can provide more information regarding Traditional Medicare coverage, Medicare Supplement Plans, Medicare Advantage Plans, Prescription Drug Plans and Special Needs Plans. It’s as easy as picking up the phone and making a simple call.
Our goal is to find the perfect insurance combination, all while saving you money. Give us a call, or fill out our online rate comparison form. Our licensed agents are available and ready to help with all your insurance needs.