The answer to that question is not as simple as it may seem, but that can be a good thing that provides you with options to pick from. In short: yes, Medicare, whether through health insurance supplements or alternative health insurance, can cover pre-existing conditions. Thanks to the protection provided by the Affordable Care Act (ACA), it is illegal for health insurance companies to deny medical coverage to someone because of their pre-existing condition. Unfortunately there can still be some complications along the way that we will be discussing more in detail throughout.
What is a Pre-Existing Condition?
In the world of health insurance, the term pre-existing condition refers to any medical condition that was previously diagnosed and treated, currently being treated, or will have to be treated. The loosely used term “previously” refers to at any point prior to applying for coverage with a new insurance company. Usually these conditions can be chronic or long term, and the severity of these conditions can vary.
How Do You Determine a Pre-Existing Condition?
The factor that determines a pre-existing condition is time. If you were diagnosed with a medical condition, received treatment for a condition, or were recommended to seek treatment in the future prior to applying for a new insurance policy, that is a pre-existing condition. Some examples are: various forms of cancer, diabetes, depression, anxiety, acne, and asthma. In the case that neither treatment nor diagnosis are present but emergent symptoms are, it could also be ruled a pre-existing condition. Luckily, with the passage of the Affordable Care Act (ACA), insurance companies cannot deny coverage or raise rates due to the existence of a pre-existing coverage if you are fortunate enough to have a qualifying health plan (QHP).
What is Medicare Supplement Insurance?
Medicare Supplement Insurance, also known as Medigap, is an insurance policy that exists to help fill in the “gaps” Original Medicare may leave uncovered. Medigap is sold and provided by private companies, and can be used to cover things like copayments, coinsurance, and deductibles. Essentially, Medigap is a supplement plan that works in conjunction with your regular Medicare policy. To get a Medigap policy you first have to be enrolled in Medicare Part A and Part B. Plans can be tailored to fit your needs so there can be additional things that Medigap can be used to cover. For example, some policies can cover things like medical care while traveling outside of the U.S.
The open-enrollment period refers to the six month period that begins once you turn 65 and enroll in Medicare Part B. It is during this time period that you have the benefit of having the guaranteed right to enroll in a supplement plan. This is ideal for those with pre-existing conditions because private companies cannot deny coverage or raise your premiums. If you happen to miss this period, you might be subjected to medical underwriting. This means that your pre-existing condition will be considered by the insurance company when deciding things like how much they will cover and pay.
Special Enrollment Period
Luckily, there is still a way to avoid medical underwriting if you miss your open enrollment period. This same technique will also help those with pre-existing conditions to avoid a waiting period and provide guaranteed issue status. You may qualify for a special enrollment period if you experienced a qualifying event, such as:
- Loss of insurance
- Change of residence
- Change in household
- If you were the victim of insurance fraud
If you experienced one of these events, you can then apply to be accepted into the Special Enrollment Period to get an insurance policy without worrying about medical underwriting or preexisting conditions.
How Medicare Supplement Insurance Covers Pre-Existing Conditions
Let’s further explain what medical underwriting is. This is a process where private insurers take pre-existing conditions into consideration when creating your policy. This is how they make judgements on who is accepted, and how much they will cover and pay for. This can’t be used during the Medicare Supplement Open Enrollment Period, meaning companies aren’t allowed to deny coverage based on a pre-existing condition.
Pre-Existing Waiting Period
There are many concerns about pre-existing conditions and health insurance qualifications. Although we already covered a few, like medical underwriting, there is an additional concern: the pre-existing condition waiting period. Generally speaking, after enrolling during the Open Enrollment Period, you cannot be subjected to a wait time for your insurance coverage to begin. Unfortunately, this isn’t always the case for those with pre-existing conditions. You may be subjected to a coverage waiting period of 6 months (maximum) before your policy’s coverage kicks in, meaning that you are responsible for paying for your care out-of-pocket while waiting. Once the period is over, your insurance company will cover your existing condition. To bypass this experience, you can accumulate a minimum of six months of creditable coverage from any of the following:
- An individual health insurance
- Employee insurance
- Other sources of qualifying health coverage
Additionally, this period does not apply to Original Medicare. It’s more commonly seen in Medicare Supplement insurance plans.
What is Not Covered By Medicare Supplement Insurance?
We previously covered what Medicare Supplement Insurance does cover, but you may be asking yourself what it doesn’t. In the event that you are in a pre-existing waiting period and are hospitalized due to your condition, you may have to pay your hospital coinsurance out-of-pocket. If during this period you are hospitalized for another, unrelated reason, your Medicare Part A will cover the coinsurance.
Alternative Health Insurance That Might Offer Pre-Existing Coverage
Another option for health insurance is the Medicare Special Needs plan (SNP), which is another subtype of the Medicare Advantage plans. The SNP is a specialized type of Medicare Advantage plan. Its benefits are better tailored to those with specialized needs. This type of plan is available to those with qualifying pre-existing conditions. A subcategory within SNPs are the Chronic Condition SNP, which is tailored to those with particular health conditions. Enrollment in this type of plan is available any time, but availability is based on location. Qualifying conditions include:
- Chronic alcoholism
- Drug addiction
- Autoimmune disorder
- Disorders of the cardiovascular system
- Chronic heart failure
- End-stage liver disease
- ESRD kidney dialysis
- Chronic lung disorders
- Chronic and disabling behavioral health conditions
- Severe hematologic disorder
If this isn’t the best insurance plan for you, you can still get coverage through Medicare Plan A and Plan B, or through a Medicare Advantage Plan.
Find the Right Medicare Supplement Plan For You
The most important takeaway is that even with a pre-existing condition, there are plenty of options to find insurance coverage. Doing the sufficient research will let you know if, how, and where your pre-existing condition is covered and what plan best suits your needs. It’s important to note what your priorities are, whether they be finding a cost effective plan or one that offers the most coverage options. To find out more about Medicare Supplement Insurance, aka Medigap, you can find more information on the Medicare.gov Insurance Supplements page. If you want to start browsing through different insurance plans feel free to contact GoMedigap at 855-908-2310 or read this informative article about preexisting conditions.