You are not alone if you have a pre-existing condition. The Centers for Medicare and Medicaid Services (CMS) reported that 50 to 129 million Americans who are not elderly, which may account for 19 to 50% of all non-elderly Americans, already have at least one pre-existing condition. The rate of Americans who have pre-existing conditions rises to 86% of people between the ages of 55 to 64. Historically people were often denied health care overage if they had a pre-existing condition. Those with cardiovascular disease, cancer or other chronic health problems often found themselves caught in this situation.
The rules changed in 2014, and several sources, including the HHS, now report that health insurers cannot deny coverage for you or your child who has a pre-existent condition. They also cannot limit treatment for pre-existing conditions.
Does Medicare Cover Pre-Existing Conditions?
Medicare follows the federal laws regarding health care coverage for pre-existing conditions. This means that if you have Original Medicare, you will receive coverage for a pre-existing condition, even if you have more than one health issue that could be considered pre-existing.
Individuals with pre-existing conditions who sign up for Medicare Advantage will also not be denied coverage or charged more. Keep in mind prices may vary since it is private insurers who offer the Medicare Advantage plans and set pricing.
Does a Medicare Supplement Plan (Medigap) Cover Pre-Existing Conditions?
Medigap is administered by private insurance companies to fill in the coverage “gaps” that Original Medicare does not provide.
The ideal time to purchase a Medigap policy is during the six-month open enrollment period where prices and choices will typically be better. The open enrollment period starts the first month you have Medicare Part B and you are aged 65 or older. During this open enrollment period you cannot be denied coverage and it can be purchased at the same price as people without pre-existing conditions. If questions or issues arise during this period, you may considering contacting the State Health Insurance Assistance Program (SHIP) which free service that helps individuals understand and manager their Medicare coverage.
If you look to purchase a Medigap policy outside of open enrollment, you run the risk that insurance company will not be able to offer you a policy.
Once you enroll in Original Medicare Part B, there is a six-month open enrollment period for Medigap. During this six-month period, you may receive a denial of coverage or may be required to pay more because of your pre-existing condition. Medigap insurers can delay providing coverage for your pre-existing condition for up to six months (known as the pre-existing waiting period).
Note people who purchase a Medigap Plan cannot have a Medicare Advantage Plan at the same time.
Can you Change Medicare Supplement Plans With Pre-existing Conditions?
Medicare indicates that any standardized Medigap plan “is guaranteed renewable even if you have health problems.” That means that even if you have health issues, the insurance company cannot cancel the policy as long as you pay your premium.
If you decide to drop the Medigap Plan, Medicare cautions you to be careful of the timing. You may have to pay a late enrollment penalty. You also cannot have both a Medicare Advantage Plan and a Medigap Plan.
- Pre-existing Conditions, HHS.
- At Risk: Pre-existing Conditions Could Affect 1 in 2 Americans, CMS.
- How Original Medicare Works, Medicare.