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Does Medicare cover preexisting conditions?

 Yes, a big benefit of Medicare, especially as you get older, is that you can’t be denied coverage or charged more because of preexisting medical conditions. Plus, if you’re younger than 65 and have certain medical conditions, you may be able to qualify for Medicare coverage early. 

Most people younger than 65 who receive Social Security Disability Insurance (SSDI) benefits can qualify for Medicare 24 months after they become eligible for disability benefits. And people younger than 65 may qualify for Medicare without the 24-month waiting period if they have permanent kidney failure, also known as end-stage renal disease (ESRD), or amyotrophic lateral sclerosis (ALS), better known as Lou Gehrig’s disease. 

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Does Medigap cover preexisting conditions?

Maybe. The rules are different for Medigap coverage, a federally regulated private insurance that many people with traditional Medicare buy to help pay Medicare’s deductibles and copayments. If you’re 65 or older, federal law allows you to buy a Medicare supplement policy with full protections if you do so within certain specified time frames.

Everyone 65 and older on Medicare qualifies for these protections, known as guaranteed issue rights, for the six-month period after you enroll in Medicare Part B benefits. That means insurance companies cannot refuse to sell you a Medigap policy or charge you higher premiums based on your current health or medical conditions. Some people qualify beyond that time frame; see details below.

If you apply for a Medigap policy when you don’t have a guaranteed issue right, you’ll usually have to answer questions about your health. An insurer may reject you or charge more if you’ve had certain medical conditions, usually within the past two years. But the conditions, timeframe and effect on your coverage can vary a lot by insurer and state.

When do I have a Medigap guaranteed issue right?

An insurance company can’t refuse to sell you a Medigap policy because of past or present health problems if you qualify for Medicare when you’re 65 or older:

For six months starting the month you sign up for Medicare Part B when you’re 65 or older. You’ll get the best price for any policy in your area based on your age, gender and smoking status.

Up to 63 days after you’ve lost job-based health insurance that’s considered secondary to Medicare. If you or your spouse works for a company with fewer than 20 employees and you’re 65 or older, your insurance is generally considered secondary to Medicare.

Up to 63 days after you move out of your Medicare Advantage plan’s service area or your plan leaves the business, and you decide to switch to original Medicare and buy a Medigap plan to continue your health coverage. 

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Within 12 months of enrolling in Medicare Advantage in two situations. If you signed up for a Medicare Advantage plan when you first enrolled in Medicare, you have up to 12 months to drop the plan, switch to original Medicare and get any Medigap policy in your area. If you dropped a Medigap policy to enroll in Medicare Advantage and want to switch back to original Medicare, you have up to 12 months to get the same Medigap policy. (You have up to 63 days after your Medicare Advantage coverage ends to get the Medigap policy.)

If you are younger than 65 and have Medicare because of a disability, federal law provides no protections when buying Medigap. Some states have additional guaranteed issue rights for people older or younger than 65. Contact your State Health Insurance Assistance Program (SHIP) to find out more about the rules in your area.

Does Medicare Advantage cover preexisting conditions?

Yes. More than 40 percent of Medicare beneficiaries choose to get their health and drug coverage through a private Medicare Advantage plan, rather than from original Medicare. 

Preexisting conditions do not affect Medicare Advantage enrollment, and that includes people with end-stage renal disease. Until recently, people with kidney failure could get coverage only through original Medicare.

The 21st Century Cures Act of 2016 changed the rules and permitted people with permanent kidney failure to enroll in Medicare Advantage plans beginning Jan. 1, 2021. Now they can choose between original Medicare or Medicare Advantage coverage. 

However, you can enroll in Medicare Advantage only during certain times, such as during the seven-month initial enrollment period surrounding your 65th birthday or during the annual open enrollment period from Oct. 15 to Dec. 7 for coverage starting on Jan. 1. Medicare Advantage plans must cover at least as much as original Medicare, and some offer additional benefits, such as dental, hearing and vision services. 

Some Medicare Advantage plans also offer additional coverage to people with chronic conditions, such as meal delivery and transportation to medical appointments. One type of Medicare Advantage plan called a Special Needs Plan (SNP) provides coverage for certain groups of people, including plans that focus on coverage for people with chronic conditions, such as diabetes, heart failure or kidney failure. 

Before choosing a Medicare Advantage plan, make sure the plan provides coverage for your doctors and specialists, the hospital where you would want to receive care, and any special care for your condition.

Keep in mind

If you are younger than 65 and on Medicare because of a disability but have been rejected for a Medigap policy or qualify only for one that charges you very high premiums, the clock will reset when you turn 65. 

At 65, you will be eligible for Medicare based your age instead of your disability. And you will be able to buy any Medigap policy with full federal protections if you purchase it within six months of signing up for Part B or qualify for other federal or state guaranteed issue rights.

Published May 23, 2022


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