Does Medicare Cover Pre-existing Conditions?
Medicare Benefits Solutions
Jan 19, 2023
If you’re new to Medicare because you’re turning 65, you may be wondering if you can enroll in coverage even though you’ve been previously diagnosed with a disease. Fortunately, there are no restrictions to Medicare coverage based on pre-existing conditions.
For anyone enrolling in Medicare for the first time, you may be wondering what criteria you must meet to qualify for coverage. You’ll be eligible for Medicare when you turn 65 as long as you are a resident of the United States. But, you may qualify for coverage under the age of 65 if you have certain disabilities, such as ESRD (end-stage renal disease) or ALS.
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What are Pre-existing Conditions?
A pre-existing condition is a health issue that existed prior to enrollment in a health insurance policy. According to the Centers for Medicare & Medicaid Services, up to 86% of older Americans (ages 55 to 64) have a pre-existing health condition.
Examples of pre-existing health conditions:
- High blood pressure
- Cardiovascular disease
- Sleep apnea
The Affordable Care Act prohibits insurance companies from denying coverage, charging exorbitant premiums, imposing an extended waiting period and limiting benefits due to a pre-existing condition.
What Pre-existing Conditions are Covered by Medicare?
At age 65, Americans are eligible to enroll in Part A and Part B without regard to pre-existing conditions, such as asthma, cancer, or diabetes. Your access to coverage will not be affected by any treatment you require.
When you turn 65, you’ll have a 7-month Initial Enrollment Period during which you can sign up for Medicare. Most people get premium-free Part A based on taxes paid while working. Part B (medical insurance) is an optional coverage, but most people enroll when they’re first eligible to avoid late enrollment fees.
Medicare Part D, prescription drug coverage, is optional. However, if you delay enrollment, you will need to have creditable prescription drug coverage to avoid a late enrollment penalty should you decide to sign up later. Creditable coverage means that you have prescription drug coverage with benefits comparable to Medicare’s standard drug plan.
If you’ve been diagnosed with a disease or condition that requires specific medications, you should compare Part D plans before enrolling. Make sure the plan you enroll in will cover the specific medications and dosages you need at a price you can afford.
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Does Medicare Cover Pre-existing Conditions if You are Disabled?
- If you are under 65 and have a disability, enrollment in Part A and Part B is automatic after receiving Social Security or certain Railroad Retirement Board disability benefits for 24 months.
- People younger than 65 with amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrig’s disease, automatically get Part A and Part B starting with the initial month of Social Security disability benefits.
- If you have end-stage renal disease (ESRD), enrollment is not automatic, but you can apply before you turn 65 without a waiting period.
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Does Medicare Advantage Cover Pre-existing Conditions?
Once you’ve signed up for Original Medicare Part A and part B, you can choose to enroll in a Medicare Advantage (MA) plan. MA plans, just like Original Medicare, will cover pre-existing conditions. Since 2021, people with ESRD can enroll in MA plans.
When can you enroll in an MA plan? You can enroll during your Initial Enrollment Period when you sign up for Original Medicare. If you don’t enroll in an MA plan at that time, you can switch to an MA plan during Medicare’s Annual Enrollment Period, October 15 through December 7. Existing Medicare Advantage members can change plans one time during the Medicare Advantage Open Enrollment period, January 1 through March 31, every year.
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Pre-existing Conditions and Medicare SNP
The Special Needs Plan (SNP) is a Medicare Advantage plan for beneficiaries with specific healthcare needs or limited financial capacity.
Eligibility is limited to people who meet specific conditions, including:
- Need nursing care in an institution or at home
- Are eligible for both Medicare and Medicaid (dually eligible)
- Have certain severe or disabling chronic health issues
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Be aware that some rules are state-regulated. For example, not all states require insurers to sell Medicare Supplement plans to people under 65 who have ESRD. Also, guaranteed issue rights for beneficiaries 65 and older are in effect either annually or continuously in four states: CT, MA, ME and NY. A licensed insurance agent can help you compare plans and advise you on the regulations in your state.
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