Medicare Parts A and B do cover preexisting conditions, but some Medigap policies may have restrictions.
Preexisting conditions are chronic medical concerns that a person may have prior to taking out health insurance.
Examples of preexisting conditions include:
- cancer
- congestive heart failure
- diabetes
Although Medicare is a health program for those aged 65 and older, some people may qualify for Medicare at an earlier age if they have a disability or qualifying condition.
Preexisting conditions may affect a person’s ability to get a supplementary Medicare policy (Medigap). This article will cover how preexisting conditions may affect Medicare coverage.
A person can have several preexisting conditions and still qualify for Medicare coverage.
Whether or not a person has preexisting conditions, premiums will be the same for the following:
- Part A: hospital coverage
- Part B: medical coverage, such as doctor’s visits
- Part C: Medicare Advantage, where a private insurance company manages a person’s Medicare plan
- Part D: prescription drug coverage
Even though private insurance companies run Medicare Advantage policies, they are under the same rules as the Affordable Care Act (ACA).
Before the federal government passed the ACA, an insurance company could deny a person with preexisting conditions a policy entirely or charge them a significantly higher premium.
As a result of the ACA, this is no longer the case, and a company offering a Medicare Advantage plan cannot deny a person coverage based on their preexisting conditions.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Supplemental insurance plans — often known as Medigap plans — are available alongside Medicare. These plans have specific rules when it comes to preexisting conditions.
Medigap policies are optional plans that private insurance companies sell to those with Original Medicare. These standardized plans help pay for out-of-pocket costs associated with Medicare, such as:
- coinsurance
- copayments
- deductibles
Enrollment exceptions
A private insurance company cannot deny a person with preexisting conditions a Medigap plan if the person is in their Medicare Initial Enrollment Period (IEP).
The IEP starts 3 months before a person turns 65 and ends 3 months afterward.
During an IEP, an insurance company must sell a Medigap policy regardless of preexisting conditions. However, when a person is outside of their IEP, the company can deny them a Medigap policy. Alternatively, the individual might be subject to higher costs.
For this reason, a person can usually get the lowest possible cost by applying for a Medigap policy when they first qualify for Medicare.
End stage renal disease (ESRD) exceptions
ESRD is a condition in which a person’s kidneys no longer function, and they require dialysis or a kidney transplant.
Those with ESRD can qualify for Medicare before the age of 65, as long as they meet specific requirements relating to dialysis.
Having this preexisting condition means that a person will usually get their coverage through Original Medicare only. However, a few exceptions exist in relation to Medicare Advantage (Part C).
If a person had Medicare Advantage before a doctor diagnosed them with ESRD, they would still be eligible to remain on their current plan.
They could also choose to switch to a different plan with the same insurer.
A person may also qualify for a new Medicare Advantage plan if their kidney transplant was successful, and they no longer require dialysis, or if they wish to join a specialized plan for those with certain medical conditions.
Some insurance companies offer specialized Medicare Advantage plans for individuals with preexisting conditions.
These plans, which are called Special Needs Plans (SNPs), are for those with chronic conditions. These conditions may include:
If a person is eligible for Medicare and has a chronic preexisting condition, they may be able to get an SNP.
SNPs are not available in all regions and states. A person can search for available plans in their area using Medicare’s Plan Finder.
Regardless of whether or not someone has preexisting conditions, they will be able to get a Medicare plan if they are over 65 years of age.
Preexisting conditions do not affect premiums either, so the cost will be the same.
Purchasing a Medigap policy when a person first qualifies for Medicare will usually be more cost effective. It can be more difficult for a person with preexisting conditions to get a Medigap policy outside of their IEP.
Original Medicare and Medicare Advantage plans provide cover for many medical conditions and routine care, but for those with eligible chronic conditions, SNPs may be available.
SNPs are not available in every area, and they may be subject to geographical restrictions.