Medicare, the U.S. federal health insurance program, is a lifeline for millions of individuals, especially those aged 65 and older or with certain disabilities.

However, one question often emerges when discussing Medicare…

Does it cover pre existing conditions? 

Under the Affordable Care Act, health insurance companies participating in the Federally Facilitated Health Insurance Marketplace are prohibited from refusing coverage or charging more to individuals because they have a “pre-existing condition”.

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This provision includes Original Medicare and Medicare Advantage Plans, but does not always include Medicare Supplement Insurance Plans. 

For instance, a Medigap policy may impose limitations related to pre-existing conditions, but these must be clearly stated in the policy.

Understanding the nuances of coverage of pre-existing conditions is crucial, as it can significantly impact healthcare accessibility and costs for beneficiaries.

This blog aims to delve into this topic in greater detail.

Understanding Medicare and Pre-Existing Conditions

A pre-existing condition is a health problem you had before the date a new insurance policy starts.

Original Medicare, a comprehensive health insurance program administered by the federal government, is divided into two primary parts: 

Medicare Part A

Medicare Part A, also known as hospital insurance, covers inpatient hospital care, skilled nursing facility care, hospice care, lab tests, surgery, and home health care. After you pay the deductible for your benefit period, Medicare Part A covers 100 percent of hospital-specific costs for the first 60 days of an inpatient stay (for those items Medicare covers). For days 61-90, Part A coverage is less comprehensive, and beyond day 90, you can use up to 60 “lifetime reserve days,” although these come with higher out-of-pocket costs.

Medicare Part B

Medicare Part B, or medical insurance, covers two types of services: medically necessary services (services or supplies needed to diagnose or treat your medical condition), and preventive services (healthcare to prevent illness or detect it at an early stage). This includes services from doctors and other healthcare providers, outpatient care, durable medical equipment, home health care, and some preventive services.

The good news for potential enrollees with pre-existing conditions is that Original Medicare provides coverage for medical conditions irrespective of whether they were diagnosed before the start of the coverage. This is a significant relief to many individuals who may be battling chronic illnesses and are worried about the financial burden of treatment.

Moreover, this coverage extends to Medicare Advantage Plans, also referred to as Medicare Part C. These plans are an alternative way to get your Medicare coverage and benefits may widely vary from plan to plan, as well as by region.  It may be useful to speak with a licensed health insurance sales agent to help navigate your options

If you opt for a Medicare Advantage Plan, you can rest assured that your pre-existing conditions will be covered, insofar as Medicare provides coverage for the specific treatment needed.  It is important to remember that Medicare does not cover everything, and it is important to be proactive to determine what your costs may be before scheduling treatment.  A good way to determine if your desired treatment is covered is by calling 1-800-MEDICARE.

The Role of Medicare Supplements in Covering Pre-Existing Conditions

When delving into the topic of Medicare and pre-existing conditions, one cannot overlook Medicare Supplement Insurance Plans, more commonly referred to as Medigap. As the name suggests, these policies are designed to fill the “gaps” in Original Medicare coverage.

However, the rules pertaining to pre-existing conditions under Medigap policies are slightly different.  Let’s start with an overview of what Medigap options are available.

What are the options for Medicare Supplement Insurance Plans?

Medigap, also known as Medicare Supplement Insurance, is a type of insurance policy that helps cover the “gaps” in Original Medicare coverage.

These policies are sold by private insurance companies and are standardized by the federal government into eleven different plans, each identified by a letter from “A” through “N”.

• Plan A provides the basic benefits to help with copayments for services covered under Medicare Parts A and B.
• Plan B includes the same benefits as Plan A, but also covers the Medicare Part A hospital deductible.
• Plan C offers the same coverage as Plan B but adds coverage for skilled nursing care coinsurance, Medicare Part B deductible, and 80% of foreign travel emergency care (up to plan limits)1. Please note that as of January 1, 2020, Plan C is not available to those newly eligible for Medicare.
• Plan D provides the same benefits as Plan C, except it doesn’t cover the Medicare Part B deductible.
• Plan F is one of the most comprehensive Medigap plans and covers all the benefits of Plan C, as well as 100% of Medicare Part B excess charges. As of January 1, 2020, Plan F is not available to those newly eligible for Medicare.
• Plan G offers the same coverage as Plan F, except it does not cover the Medicare Part B deductible.
• Plan K provides 50% coverage for several items including Part A deductible, Part B copayment/coinsurance, first three pints of blood, hospice care coinsurance/copayment, skilled nursing facility care coinsurance, and the out-of-pocket limit.
• Plan L is similar to K, but provides 75% coverage for the same items.
• Plan M covers the same benefits as Plan D, but covers only 50% of the Part A deductible and none of the Part B deductible.
• Plan N covers the same benefits as Plan D, but with a co-payment for some office visits and emergency room visits.

It’s important to note that not every insurance company sells all 11 Medigap policies, and prices can vary among insurers for the same policy. Furthermore, Massachusetts, Minnesota, and Wisconsin standardize their Medigap policies differently than the rest of the country.

During your Medigap Open Enrollment Period, which starts the month you’re 65 or older and enrolled in Medicare Part B, insurance companies are not allowed to use medical underwriting. Essentially, this means they can’t refuse to sell you any Medigap policy they offer, or charge you more for a Medigap policy based on your health status.

However, if you apply for a Medigap policy after this enrollment period, there’s no guarantee that an insurance company will sell you a policy if you don’t meet the medical underwriting requirements.

Underwriting and Medicare Supplements: What You Need to Know

Underwriting is a standard process employed by insurance companies when evaluating an applicant’s suitability for a policy. Underwriters assess an individual’s health status when they apply for a policy, determining the level of risk the insurer would take on by providing coverage.

If you apply for a Medigap policy when you have a guaranteed issue right, insurance companies are required by law to sell you a policy, cover all your pre-existing conditions, and can’t charge you more for a policy because of past or present health problems.

State Variations in Medicare Supplement Policies for Individuals Under 65

Medicare Supplement insurance policies offer critical coverage to fill the “gaps” in Original Medicare. However, it’s important to note that the rules and availability of these policies can vary widely depending on state regulations, particularly for individuals under 65 years old.

Under federal law, a 6-month “Medigap Open Enrollment” period is provided, starting the first month you have Medicare Part B and you’re 65 or older. During this period, you cannot be denied a Medigap policy or charged more based on your health status. However, for those under 65, the scenario can be quite different.

Federal regulations do not guarantee eligibility for Medicare Supplemental Insurance Plans to individuals under age 65 who are eligible for Medicare due to disability. This situation means that each state has the discretion to determine whether Medigap policies are available to those under 65.

For instance, in Texas, the right to purchase Medigap policies for those under 65 and on Medicare is limited to Medicare Supplement Plan A. On the other hand, in New Jersey, the Contracted Carrier must charge individuals under age 50 the same premium for the Medicare Supplement Plan purchased as the carrier charges to those age 65.

Furthermore, in Indiana, Medicare supplemental insurance companies cannot deny coverage, charge higher premiums, or impose a waiting period because of disability or health conditions, even for those under 65.

The best time to sign up for a Medigap plan is during the first six months in which you are age 65 or older and enrolled in Part B. Outside of this period, states may have different rules about enrolling in a Medigap policy if you’re under 65.

To summarize, while Original Medicare provides a safety net for many Americans, understanding the nuances of Medicare Supplement Insurance Plans, especially for those under 65, can be complex due to varying state rules. Therefore, it’s crucial to contact your state’s Department of Insurance or a licensed health insurance sales agent to understand the specific rules applicable in your state.

In conclusion, Original Medicare does indeed cover pre-existing conditions. As mandated by the Affordable Care Act, health insurance companies participating in the Federally-Facilitated Health Insurance Marketplace, as well as Original Medicare, cannot refuse coverage or impose higher charges based on a pre-existing condition. This is a significant protection for individuals who may be dealing with chronic illnesses or health issues.

Medicare Advantage Plans, an alternative to Original Medicare, also extend this coverage. These plans, offered by private companies approved by Medicare, ensure that pre-existing conditions do not hinder beneficiaries from receiving healthcare.

However, when it comes to Medicare Supplement Insurance Plans, or Medigap, the rules can vary. While these policies fill in the “gaps” in Original Medicare coverage, they may impose limitations related to pre-existing conditions, particularly if you are enrolling outside of your Open Enrollment Period.

The concept of pre-existing conditions has long been a point of contention in the health insurance landscape. Yet, the current provisions under Original Medicare offer a level of reassurance. They ensure that beneficiaries, regardless of their health status at the time of enrollment, have access to care. As healthcare policies continue to evolve, it’s essential to stay informed and understand your rights and protections.

It may be useful to speak with a licensed health insurance sales agent to help navigate the nuances and complexities of health insurance.

Sources:

• “Can I get coverage if I have a pre-existing condition?” HHS.gov. ↩
• “Pre-Existing Conditions” HHS.gov. ↩
• “Marketplace health plans cover pre-existing conditions” Healthcare.gov. ↩
• “Things to know about Medicare Advantage Plans” Medicare.gov. ↩
• “Medicare Supplement Insurance – Official Website” doi.sc.gov. ↩ ↩2
• “Medicare supplement insurance guide” tdi.texas.gov. ↩ ↩2 ↩3 ↩4 ↩5 ↩6
• “Things to know about Medicare Advantage Plans” https://www.medicare.gov/things-to-know-about-medicare-advantage-plans
• “Medicare Supplemental Insurance, Pre-Existing Condition …” https://www.dfs.ny.gov/insurance/ogco2005/rg050920.htm
• “RCW 48.66.130: Pre-existing condition limitations.” app.leg.wa.gov 
• “Medicare supplement insurance guide” tdi.texas.gov. ↩
• “When can I buy a Medigap policy?” Medicare.gov
• “2023 Choosing a Medigap Policy.” CMS
• “Get ready to buy | Medicare” Medicare.gov
• “Costs of Medigap policies” Medicare.gov
• “Medicare Supplement Plans” ncdoi.gov
• “Medicare supplement insurance guide” tdi.texas.gov
• “Medicare Supplement Under 50 Program – Introduction” nj.gov
• “Under Age 65 and Disabled?” in.gov
• “When can I sign up or switch Medigap plans?” insurance.wa.gov
• “What Medicare covers”: www.medicare.gov/what-medicare-covers
• “Question: Does Medicare Part A cover 100 percent?”: www.medicare.gov/questions-and-answers/
• “What Part B covers”: www.medicare.gov/what-medicare-covers/what-part-b-covers
• “Compare Medigap Plan Benefits” www.medicare.gov/health-drug-plans/medigap/basics/compare-plan-benefits
• “What you need to know about Medigap (Medicare …” www.insurance.wa.gov/sites/default/files/documents/what-you-need-to-know-medigap-plans_4.pdf
• “Connecticut Insurance Department – Medigap Fact Sheet” portal.ct.gov/-/media/CID/MedigapFactSheetpdf.pdf?la=en
• “Medicare Supplement Plans” www.in.gov/ship/medicare-supplement-plans/
• “Medigap – Missouri Department of Insurance” insurance.mo.gov/seniors/srmedigap.php
• “Medicare Supplement Guide” insurance.ky.gov/ppc/Documents/MSGuide012021.pdf 

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