If you suffer from a pre-existing medical condition, you might be worried that your situation will affect the cost and quality of your health coverage. With Original Medicare and Medicare supplement plans like Medicare Advantage, it’s especially difficult to know if and when a policy will cover costs associated with your condition. For the most part, it is possible to get full coverage for a pre-existing condition under Medicare Advantage if you enroll on time. But keep in mind that there are several factors to consider if you’re looking to receive immediate benefits for your condition.

Key Takeaways

  • Medicare Advantage plans will cover pre-existing conditions if you enroll on time.
  • It is illegal for Original Medicare or Medicare Advantage plans to discriminate against those with pre-existing conditions.
  • Those diagnosed with End-Stage Renal Disease are only eligible for Medicare Advantage in specific situations.
  • Medicare Advantage, Medigap, and Medicare Part D plans offer supplemental coverage that isn’t provided by Original Medicare.
  • Medigap policy providers may deny or delay coverage to those with pre-existing conditions using medical underwriting or a pre-existing condition waiting period.

Medicare vs. Medicare Advantage

Original Medicare is a federal health insurance program that provides quality healthcare to seniors 65+ and adults with disabilities. Medicare plans have two distinct parts: Part A, which covers inpatient hospital services, and Part B, which covers outpatient medical services. While Parts A and B cover basic healthcare, they do not cover all medical services that are necessary for seniors and/or those with pre-existing conditions. Those gaps can be covered by Medicare Advantage, a Medicare supplement plan that combines all benefits into one policy. Medicare Advantage, also known as MA or Part C plans, include Parts A, B, and D (prescription drugs). The additional benefits offered by Medicare Advantage are ideal for those with pre-existing conditions, as they typically provide more medical services.

It is illegal for Original Medicare or Medicare Advantage providers to discriminate against those with pre-existing conditions. The exception to this law applies only to those with End-Stage Renal Disease (ESRD), also known as kidney disease. Those with ESRD are eligible for Medicare Advantage in specific situations, which are explained below.

If you’re interested in a Medicare Advantage plan, be sure to read each policy thoroughly before purchasing. Each policy has its own rules for out-of-pocket costs, coverage, and patient responsibility. Medicare Advantage plans can be found on the Medicare plan-finder tool.

Those interested in Medicare Advantage must already be enrolled in Original Medicare Parts A and B. To enroll in Original Medicare, you must apply during the 7-month long initial enrollment period. This period begins 3 months before you turn 65 and ends 3 months after you turn 65. For example, if you turn 65 in June, your Medicare enrollment period is between March and September. In most cases, not signing up for Part B when you’re first eligible may result in a late penalty fee. Additionally, waiting until the same month you turn 65 to enroll could result in Part B coverage being delayed, therefore causing a gap in your coverage.

Anyone interested in enrolling in Medicare plans should be wary of Medicare Advantage scams. Medicare and supplemental insurance providers are not allowed to enroll you in a plan over the phone unless you specifically ask. They are not allowed to ask you for bank information over the phone. If you receive an unsolicited call from someone trying to sell Medicare products, you can report it online or by calling 1-800-MEDICARE.

End-Stage Renal Disease

Those with ESRD will likely get primary insurance through Original Medicare. It is possible to join a Medicare Advantage plan only if the following situations apply to you:

  • You develop ESRD while already enrolled in a Medicare Advantage plan
  • You are already receiving health coverage through the same company that offers the Medicare Advantage plan
  • You have received dialysis or a successful kidney transplant and qualify for Original Medicare benefits

If you have ESRD, you are likely eligible for a Medicare Special Needs Plan (SNP).

Medicare Advantage, Pre-Existing Conditions, and Medicare Supplement Insurance

Medicare Advantage is just one of many forms of Medicare supplement insurance. If Medicare Advantage isn’t right for you, you may want to consider a Medicare Part D or Medigap policy.

Medicare Part D, also known as a PPD plan, covers prescription drug coverage in addition to Part A and B benefits. Those who are already enrolled in Parts A and B are eligible to apply for a Part D plan if prescription drug coverage is essential in your healthcare.

Medigap is supplemental insurance that you can purchase from a private company to pay for the healthcare costs not covered by Original Medicare, such as copayments, deductibles, and healthcare outside of the U.S. To be eligible for a Medigap policy, you must already be enrolled in Original Medicare. Those with pre-existing conditions should be cautious when purchasing a Medigap policy, as Medigap providers are allowed to deny coverage if you apply outside of the Open Enrollment period.

Companies can deny coverage using medical underwriting – a process in which insurers look at an applicant’s medical history to decide who will be approved for coverage and how much they will pay. Insurers cannot use this process during the Medicare supplement Open Enrollment period, so those who apply within that period will not be refused coverage or be overcharged if they have a pre-existing condition. The Open Enrollment period lasts 6 months and begins the first day of the month in which you’re both 65+ and enrolled in Medicare Part B. If you apply outside of that 6-month period, you may be subject to medical underwriting and be denied or overcharged for a pre-existing condition.

If you apply during the Open Enrollment period, an insurance company might make you wait for coverage to start if you have a pre-existing condition. This is known as the “pre-existing condition waiting period,” and Medigap providers are allowed to refuse coverage for costs associated with your condition. This waiting period can last up to 6 months, during which you’ll be responsible for any out-of-pocket medical costs you incur. After 6 months, the Medigap policy will begin to cover your condition. It’s possible to avoid or shorten this waiting period if you had adequate health coverage at least 6 months before the start of your Medicare Supplement plan. If you’re replacing an old health plan with Medigap or other supplemental insurance, it’s unlikely that you’ll have to wait for coverage for your pre-existing condition.

On a final note, keep in mind that Medicare Advantage plans do not have these restrictions as long as you apply within the Open Enrollment period and do not currently have End-Stage Renal Disease.