A pre-existing health condition is a health complication that exists prior to a health insurance contract. Those with pre-existing conditions can sometimes feel hesitant to apply for coverage.
However, Traditional Medicare isn’t dependent on the status of your health. Meaning any pre-existing health conditions won’t impact eligibility for Medicare Part A or Medicare Part B.
Although, this isn’t the case for Medicare Advantage Plans or Medicare Supplement Plans.
Beneficiaries that receive Medicare-covered services for pre-existing conditions will have coverage from Medicare.
However, if the Medigap policy doesn’t cover the out-of-pocket costs, you’ll be responsible for that copayment or coinsurance.
Pre-Existing Conditions Not Covered by Medicare
Original Medicare consists of two parts, Medicare Part A and Medicare Part B. However, there are gaps in these coverages. Such as deductibles, the 20% coinsurance for services as well as excess charges of up to 15%.
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.
Medigap Pre-existing Condition Waiting Period
Medigap Plans help cover deductibles, copayments, coinsurance as well as other medical costs that not covered by Traditional Medicare.
Purchasing a 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, private insurance companies offering Medicare Supplement Plans are required to provide you health insurance.
Failing to enroll during the OEP subjects’ seniors to the underwriting process. During underwriting, insurance carriers can deny coverage or increase monthly premiums based on underlying health issues.
Although, if the Medigap company refuses to cover out-of-pocket expenses, they can only do this for 6 months. The pre-existing condition waiting period really only applies to Medigap plans.
Medicare will cover your pre-existing condition on covered services. However, for the first 6 months, 20% of out of pocket costs will be covered by you.
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.
However, there are restrictions regarding individuals suffering from End Stage Renal Disease (ESRD) trying to obtain a Medicare Advantage Plan.
Private insurance companies sell Medicare Advantage plans to Medicare beneficiaries. Medicare Advantage Plans are purchased to take over coverage for Traditional Medicare Parts A and B.
This is why Medicare Advantage Plans are called Medicare Replacement Plans.
Those with ESRD aren’t eligible for enrollment unless you:
- Have a Medicare Advantage Plan at the time of being diagnosed with End Stage Renal Disease
- Enrolled in health care coverage through an employer and that specific insurance company also provides Medicare Advantage Plans
- Had 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
- Had a successful kidney transplant, thus resolving your ESRD, while still be eligible for a Medicare Advantage Plan
- Find an ESRD Medicare Special Needs Plan (SNP), which is a type of Medicare Advantage Plan
Special Needs Plans & Pre-Existing Conditions
Medicare Advantage Special Needs Plans have to include Medicare Part D. Medicare Part D is usually a stand-alone Prescription Drug Plan offered through an individual insurance company.
Special Needs Plans combine Medicare Parts A, B, and D. However, individuals suffering from certain health conditions are the only ones eligible.
Occasionally, these types of plans may offer extra benefits, tailored for the individual’s health care needs.
These extra benefits include:
- Routine dental
- Hearing care
- Non-emergency health care transportation to and from office visits
- Over-the-counter medication assistance
- Fitness programs
Special Needs Plans provide extra healthcare benefits to help manage your individual health condition.
Who Qualifies for a Special Needs Plan?
A variety of SNP’s are available as well as plans for individuals with chronic, pre-existing conditions.
Specific requirements for this plan include:
- Location, you must live in an area where the SNP is available
- Enrolled in Medicare Part A and Medicare Part B
- Residency in certain institutions such as a skilled nursing facility, intermediate care facility or Assisted Living Facility (ALF)
Individuals 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
- Diabetes Mellitus
- Chronic cardiovascular disease
- End-stage liver disease
- Chronic heart failure
- End Stage Renal Disease (ESRD) requiring dialysis
- Hematological disorders (deep vein thrombosis or DVT’s, Sickle Cell Anemia, Thrombocytopenia)
- Chronic lung disorders (Asthma, COPD, Emphysema, Pulmonary Hypertension)
- Neurological disorders (Epilepsy, Multiple Sclerosis, Parkinson’s Disease, ALS)
- Certain, disabling behavioral health conditions
Once declared eligible for a chronic condition, you can enroll at any time if a local plan is available.
However, if your situation changes and you no longer qualify, you can utilize the Special Election Period to change your coverage.
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 Medicare coverage. 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.