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.

Key Takeaways

  • Having a medical condition at the time of applying for a new healthcare policy may affect how much coverage you’ll receive and at what cost.
  • If you have a qualifying health plan under the Affordable Care Act, your insurance provider cannot deny coverage or raise rates based on a pre-existing condition.
  • Private insurers, however, can use medical underwriting or waiting periods to take pre-existing conditions into consideration when creating health policies.
  • Private insurers cannot use medical underwriting during the Medicare Supplement Open Enrollment period.
  • Medicare Special Needs plans offer benefits specifically for those with specialized needs.

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 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 must have enrollment 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.

Open-Enrollment Period

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 insurance companies will consider your pre-existing condition when deciding the amount and cost of the coverage you’ll receive.

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 experience one of these events, you can apply for a Special Enrollment Period to get an insurance policy without worrying about medical underwriting.

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 judgments on who is accepted, and how much they will cover and pay for. Insurance companies cannot use medical underwriting during the Medicare Supplement Open Enrollment Period.

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
  • TRICARE
  • Other sources of qualifying health coverage

Additionally, this period does not apply to Original Medicare. It only applies to certain Medicare Supplement insurance plans.

What Doesn’t Medicare Supplement Insurance Cover?

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 specifically for 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 SNPs, which are specifically for those with chronic 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
  • Cancer
  • Disorders of the cardiovascular system
  • Chronic heart failure
  • Diabetes
  • End-stage liver disease
  • ESRD kidney dialysis
  • HIV/AIDS
  • Chronic lung disorders
  • Chronic and disabling behavioral health conditions
  • Dementia
  • Severe hematologic disorder
  • Stroke

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 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.

by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.
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