Does Medicare Cover Preexisting Conditions?

How Preexisting Condition Coverage Works Under Medicare

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Getting the health care you need can be expensive, and as you age, you’re more likely to have conditions that require ongoing care. Consider that approximately 51% of Americans over the age of 18 have at least one chronic health condition, and that figure rises to 85% for Americans aged 65 and older. 

Since 65 is the age at which most Americans qualify for Medicare, you may be wondering if you can get affordable health care coverage with preexisting conditions. The short answer is yes. To explain the long answer, we’ll explore how preexisting condition coverage works under Medicare. 

Key Takeaways

  • Original Medicare and Medicare Advantage Plans cover preexisting conditions.
  • You can’t be denied coverage or charged more for Original Medicare or Medicare Advantage Plans due to preexisting conditions. 
  • Medigap covers preexisting conditions without any additional costs if you sign up during the six-month Medigap Open Enrollment period.

Preexisting Conditions Under Original Medicare

Before January 1, 2014, health insurers could charge you more or deny you coverage if you had a preexisting condition like cancer, diabetes, or asthma. However, on that date, the Affordable Care Act (ACA) went into effect, prohibiting these activities. 

That means your eligibility for Original Medicare (which includes Part A and Part B) is not affected by any preexisting conditions. Likewise, if you need to enroll in Medicare Part D for prescription drugs, you can get coverage regardless of whether you have preexisting conditions, as long as you’re enrolled in Medicare Parts A and/or Part B.

There is an exception to this rule. Grandfathered individual health insurance plans that you bought independent of an employer on or before March 23, 2010, aren’t required to cover preexisting conditions.  

Medicare Advantage and Preexisting Conditions

Also known as Medicare Part C, Medicare Advantage plans offer a way to get Medicare Parts A and B benefits from private insurance companies. In many cases, these plans offer prescription drug coverage and cover expenses Original Medicare doesn’t, such as fees for fitness programs, vision services, dental care, and hearing assessments.

You can join a Medicare Advantage Plan whether or not you have a preexisting condition without being charged more, but you are required to be enrolled in Medicare Part A and Part B. Prices vary by provider so it’s a good idea to compare Medicare Advantage providers before you sign up.

As of January 2021, people with End-Stage Renal Disease (ESRD) are eligible for both Medicare and Medicare Advantage Plans.

Preexisting Condition Coverage With Medigap Plans

Medigap plans, also called Medicare Supplement Insurance, are policies sold by private companies that help pay for costs not covered by Original Medicare, such as deductibles, copays, and coinsurance. However, they aren’t quite as accommodating for people with preexisting conditions. 

Enrolling in Part B triggers your six-month Medigap open enrollment period. insurers can deny you coverage or charge you more for having preexisting conditions. Further, while Medigap insurance providers can’t delay your Medigap coverage for a preexisting condition, they can delay covering costs associated with the preexisting condition for up to six months.

You can shorten or avoid preexisting condition waiting periods if you’ve had at least six months of continuous creditable coverage (which includes many types of previous health insurance). However, you can’t have had a break in coverage for more than 63 days. 

When To Enroll in Medigap

Wondering when is the best time to enroll in Medigap? Here’s a look at your Medigap enrollment options:

  • Medigap open enrollment period: This six-month period starts automatically the month you’re enrolled in Part B and are at least 65 years old. During this one-time enrollment period, you can buy any policy sold by a Medigap provider in your state for the same price as someone without preexisting or other health conditions. That said, you may have to wait up to six months for coverage associated with your preexisting conditions.
  • After the Medigap open enrollment period: If you enroll after the six-month open enrollment period, you will be subject to medical underwriting by the Medigap policy provider. As a result, they can deny you coverage or charge you more based on your preexisting conditions. 
  • You have a guaranteed issue right: If you have a guaranteed issue right, such as if you move out of the service area for your Medicare Advantage plan, insurance companies can’t refuse your application for a Medigap policy or charge you more for one. And they must cover your preexisting health conditions. These are also referred to as “Medigap Protections.”
  • Before turning 65: If you aren’t yet 65, federal law doesn’t require companies to sell you a Medigap policy. However, some state laws do. If you’re able to buy a Medigap Plan before you turn 65 in your state, it may cost you more than if you wait.

If possible, it’s best to enroll during the six-month Medigap open enrollment period. This allows you to access a wide variety of plans at the lowest prices without having to qualify via an insurer’s medical underwriting process. Additionally, if you have a guaranteed issue right, you’ll also receive a guarantee that your preexisting conditions will be covered right away.

The Bottom Line

With most Americans developing at least one chronic health condition by age 65, it’s helpful that most Medicare options no longer deny coverage or increase prices based on preexisting conditions. You can get the coverage you need from Original Medicare and a Part D prescription drug plan, or from a Medicare Advantage Plan without worrying about your health limiting your coverage. But if you’re in Original Medicare and want a Medigap policy as well, be sure to apply during Medigap open enrollment to guarantee coverage. 

Frequently Asked Questions (FAQs)

What Medicare plan is better for preexisting conditions?

Original Medicare and Medicare Advantage are both great options because they don’t deny coverage or increase prices based on preexisting conditions. On the other hand, Medigap providers can deny coverage or charge more for preexisting conditions, but only after the initial six-month Medigap open enrollment period expires. 

When can I get Medicare coverage?

In most cases, you can get Medicare when you turn 65 years old. An initial enrollment period will start three months before you turn 65 and will end three months after your birth month. During those seven months, you should sign up to avoid lifetime late enrollment penalties, especially if you don’t have other health insurance coverage. If you miss your initial enrollment period, you may qualify for a special enrollment period, such as if you lose your health insurance. There is also a general enrollment period between Jan. 1 and March 31 each year, though you may face late enrollment penalties and a gap in coverage if you enroll then.

Article Sources

  1. National Institute on Aging. "Supporting Older Patients With Chronic Conditions."

  2. Health and Human Services. "Who Is Eligible For Medicare?"

  3. Department of Health & Human Services. "Pre-Existing Conditions."

  4. Centers for Medicare & Medicaid Services. "How Do Medicare Advantage Plans Work?"

  5. Centers for Medicare & Medicaid Services. "Things to know about Medicare Advantage Plans."

  6. Centers for Medicare & Medicaid Services. "Who Can Join a Medicare Advantage Plan?"

  7. U.S. Government Accountability Office. "Congressional Testimony Transcript: Plans Are Widely Available but Have Limited Benefits and May Have High Costs."

  8. Centers for Medicare & Medicaid Services. "When Can I Buy Medigap?"

  9. Centers for Medicare & Medicaid Services. "Guaranteed Issue Rights."

  10. Centers for Medicare & Medicaid Services. "Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare," Pages 14-15.

  11. Centers for Medicare & Medicaid Services. "Deciding Whether to Enroll in Medicare Part A and Part B," Page 1 and 13.