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    Does Medicare Cover Pre-existing Conditions?

    4 mins

    Does Medicare cover pre-existing conditions? The short answer is “yes.” The longer answer, which we’ll explore in this article, is “yes, but it’s not that simple.”

    What does Medicare consider to be a pre-existing condition? Any chronic or long-term conditions or diseases, such as cancer, cystic fibrosis, or heart disease are considered to be pre-existing.

    There was a time not too long ago that insurance companies could refuse to cover an individual based on a pre-existing condition, but the law now prohibits this behavior.

    This brings us back to the main question: Does Medicare cover pre-existing conditions? Read on to find out!

    What Are the Parts of Medicare?

    There are several Medicare parts, and each has its own focus of coverage. These are specific components of what’s known as Original Medicare. Individuals aged 65 or older are eligible, as are younger people with certain incurable conditions or disabilities.

    Let’s take a look at what each part does:

    • Medicare Part A: Hospital insurance, which pays for hospital stays, home health care, hospice, and skilled nursing facility care (SNF care)

    • Medicare Part B: Medical insurance that covers doctor visits, diagnostics, ambulance services, certain prescription drugs, preventive care, and wellness visits

    • Medicare Part D: Adds prescription drug coverage to Parts A and B

    Premiums in Medicare can be free if you’re eligible, but the amount you pay per month can be up to $504.90. The good news is that these rates are the same whether you have a pre-existing condition or not! And thanks to the Affordable Care Act, no one can be denied coverage due to pre-existing conditions, either.

    Medicare Advantage

    If you noticed there was no “Part C” in the above list, don’t worry — we’re going to discuss that here. It’s known as Medicare Advantage, and it covers everything that Original Medicare includes in Parts A and B. 90% of Medicare Advantage plans cover Part D, as well.

    Many plans also include dental, vision, hearing, and fitness. Medicare Advantage is offered by private health care companies, as opposed to the government. You can’t be charged more or denied because of pre-existing conditions under Medicare Advantage, either.

    But there is one way coverage can get complicated. If you’ve been diagnosed with end-stage renal disease (ESRD), you might be required to use Original Medicare or a Special Needs Plan. This doesn’t mean you’re being denied coverage — just that you need different coverage.

    A female doctor showing information to an elderly female patient
    PeopleImages via Getty Images

    What About Medigap Coverage?

    Medigap policies — or to be more technically accurate, Medicare Supplement Plans — aren’t complete policies in and of themselves. Under Medicare, you’ll still pay copays and deductibles, as well as a portion of your medical bills, but a Medigap policy can “fill in the gap” and pay for things that Medicare won’t. Some policies pay most of your bill; some pay all.

    Where Coverage CAN Be Denied

    When you’re asking, “Does Medicare cover pre-existing conditions” regarding Medicare Supplement Plans/Medigap, the answer is a bit more complicated.

    In order to be eligible for Medigap coverage, you’ll need to sign up during the eligibility window to pay the same amount as people without pre-existing conditions. Otherwise, if you try to sign up outside of that window, you can face higher costs and even a denial of coverage.

    So, yes, Medicare does cover pre-existing conditions. It’s just that in order to get that coverage under Medigap, you need to sign up at specific times.

    Pre-Existing Condition Waiting Period

    With Medigap, you may experience a “waiting period” of up to six months before your out-of-pocket expenses for your pre-existing condition will be covered. If you have “creditable coverage” — six months of continuous health coverage prior to signing up for Medigap — your provider will cover your pre-existing condition.

    If you have a Guaranteed Issue Right outside of the Medigap sign-up window, you can also avoid the waiting period.

    Some scenarios in which Guaranteed Issue Rights can be granted include:

    • Your current Medicare plan is no longer offered in your area

    • You move out of the service area

    • Your employer’s Medicare Supplement Plan ends

    • Your Medicare company broke the rules

    • Your Medigap provider went bankrupt

    Generally, the Medigap sign-up window begins the month you turn 65 and enroll in Medicare Part B.

    Your Rights

    Know that you have certain rights under Medicare! These are things people may not think about, but it’s necessary to keep them in mind to protect yourself.

    Some rights you’re entitled to include:

    • Being treated with dignity and respect

    • Not facing discrimination

    • Keeping your medical information private

    • Having access to hospitals, doctors, and specialists

    • Filing complaints

    Remember, Medicare is here to improve your health! If you’re being mistreated, you have the legal right to stand up for yourself.

    Getting Coverage

    Your pre-existing condition can’t keep you from getting health insurance. For Medigap policies, you’ll have to apply during the right window of time, but once you do, you’ll be covered. Sign up for Medicare today and get the coverage you need!

    Kristina Dinabourgski
    Kristina Dinabourgski
    Has a passion for demystifying benefits 🎉
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