Yes, Medicare Part A and Part B cover preexisting conditions, but some Medigap policies may have restrictions.

Preexisting conditions are chronic medical concerns that a person may have before taking out health insurance.

Examples of preexisting conditions include:

  • cancer
  • congestive heart failure
  • diabetes

Although Medicare is a health program for those ages 65 and older, some people may qualify for Medicare earlier if they have a disability or qualifying condition.

Preexisting conditions may affect someone’s ability to get a supplementary Medicare policy (Medigap). This article will explain how.

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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

Learn more about the types of Medicare.

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 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 due to their preexisting conditions.

Glossary of Medicare terms

We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:

  • Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
  • Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
  • Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
  • Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
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Supplemental insurance plans — often known as Medigap plans — are available alongside Medicare. These plans have specific rules regarding 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 relating to Medicare, such as:

  • coinsurance
  • copayments
  • deductibles

Enrollment exceptions

A private insurance company cannot deny a person with preexisting conditions a Medigap plan if they are in their Medicare Initial Enrollment Period (IEP).

The IEP starts 3 months before a person turns 65 and ends 3 months afterward. Including the month in which they turn 65, this period lasts a total of 7 months.

During an IEP, an insurance company must sell a Medigap policy regardless of preexisting conditions. However, when a person is outside 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 the individual requires dialysis or a kidney transplant. Those with ESRD can qualify for Medicare before the age of 65 as long as they meet specific requirements.

Having this preexisting condition means that a person will usually get coverage through Original Medicare only. However, a few exceptions exist regarding 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 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 effective and they no longer require dialysis. They may also be eligible 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, known as 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.

However, 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, if they are over 65, they can enroll in a Medicare plan.

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. However, it can be more difficult for a person with preexisting conditions to get a Medigap policy outside their IEP.

Original Medicare and Medicare Advantage plans cover many medical conditions and routine care, but SNPs may be available for those with eligible chronic conditions.

SNPs are unavailable in every area and may be subject to geographical restrictions.