Pre-existing health conditions are not excluded from coverage by Medicare Part A or Part B, but supplemental plans may delay coverage of a pre-existing condition in certain cases. Understanding how a pre-existing condition is determined and what your options are when it comes to supplementing your Original Medicare coverage will help you avoid any complications.
How Medigap Defines a Pre-existing Condition
In the simplest of terms, a pre-existing condition is defined as any health issue you may have had before your new insurance policy is due to start. Generally, you must have received a diagnosis or treatment for that condition to be defined as pre-existing.
Even if a condition is undiagnosed or untreated, it may still be possible for it to be classified as pre-existing by Medicare. This may happen if a person has a health condition with emergent symptoms for which the average person would have already established treatment.
Medicare recipients who are under the age of 65 and have certain chronic health conditions may not be eligible to purchase supplemental plans until they are 65. Each state may regulate these coverage rules differently, so you may need to check with your state’s Medicare office to verify eligibility rules.
What is an Initial Enrollment Period?
When you turn 65 and are enrolled in Medicare Part B, you will have an Initial Enrollment period for Medigap. This enrollment period begins the month you turn 65 and lasts for a total of 6 months. During this enrollment period, you can purchase any Medigap plan offered in your state without any delay in coverage for your pre-existing condition. Additionally, the insurer cannot charge you a higher premium or turn you down.
If you miss this open enrollment period and decide to purchase a Medigap plan, you may be denied coverage or charged a higher premium for a supplemental plan. However, if you have supplemental insurance through another provider after the initial enrollment period has passed, you may qualify for a special enrollment period.
What is a Special Enrollment Period?
If you experience a qualifying event that changes your current supplemental insurance, you may be eligible for a special enrollment period that will allow you to bypass a pre-existing condition waiting period. This is commonly referred to as a guaranteed issue right.
The following circumstances can trigger a special enrollment period:
- Your supplemental insurance through an employer ends, reduces the benefits it offers or you lose eligibility for it.
- Your Medicare Advantage plan’s terms change or end.
- You move out of your Medicare Advantage plan’s area of coverage.
- Your Medicare-approved supplemental or Medicare Advantage plan commits fraud.
- You decide to switch back to a supplemental plan during a trial period with a Medicare Advantage plan or a PACE organization.
A special enrollment period due for a guaranteed issue right may begin 60 days prior to a current plan’s termination and last for up to 63 days after it terminates. Depending on the circumstances for which you qualify, there may be additional restrictions placed on which supplemental plans you can choose.
What is the Pre-existing Condition Waiting Period?
In the event that you miss both the initial enrollment period and cannot qualify under a special enrollment period, you may still be able to purchase a supplemental plan. Some Medicare Supplement plans may charge you a higher premium, however, and you may have to wait up to 6 months before the policy will cover costs related to your pre-existing condition.
If you have had continuous and creditable coverage for your condition through another form of insurance for 6 months prior to your purchase of a Medigap policy, this waiting period may be waived. Even if you are given a waiting period for supplemental coverage of your pre-existing condition, Original Medicare will still cover its share of costs related to any treatment you receive.