Do Pre-Existing Conditions Affect Medicare Coverage?

A study from the United States Department of Health and Human Services (HHS) estimates that one in two Americans younger than age 65 have a pre-existing condition. The Affordable Care Act (ACA) made it so that insurance companies couldn’t refuse under-65 health coverage or charge you more if you had a pre-existing condition. What happens when you reach age 65 or qualify for Medicare coverage? Do pre-existing conditions change your Medicare coverage?

What Are Pre-Existing Conditions?

Before we look specifically into insurance coverage, we should define pre-existing conditions. The term “pre-existing conditions” is a broad group that can include any health condition that you have before your health coverage starts. These are often chronic conditions like cancer, congestive heart failure, kidney disease, or AIDs, but could also include obesity, alcoholism, and even pregnancy.

Before the ACA, individual health insurance carriers could deny enrollment or charge you more if you had any of these conditions. Their reasoning for this was that people with these conditions would generally utilize their coverage more. But, since so many people have a condition that falls under the pre-existing condition umbrella, it also meant millions of Americans were denied coverage or forced to pay extra. With the ACA’s passage in 2010, health insurance carriers can no longer use these discriminatory practices for new enrollees.

Medicare Coverage and Pre-Existing Conditions

You’re likely wondering if the ACA ruling also applies to Medicare coverage and plans. Original Medicare (Parts A and B), Medicare Advantage (Part C) , and prescription drug plans (Part D) are all forms of primary health care coverage and regulated by the ACA just like non-Medicare health insurance plans. That means, if you’re looking at these Medicare plans and you have a pre-existing condition, you will be able to enroll and won’t be charged more because of your condition by the insurance company.

This is great when you consider that somewhere between 48 percent and 86 percent of Americans ages 55 to 64, approaching the age of Medicare eligibility, have a pre-existing condition, according to HHS. Remember that you can also qualify for Medicare if you’re receiving Social Security Disability Insurance (SSDI) or have Lou Gehrig’s Disease (ALS) or End-Stage Renal Disease (ESRD). Any of these qualifying conditions are considered pre-existing ones. Without these protections, millions of Medicare beneficiaries could be left without coverage.

Pre-Existing Conditions and Medigap

What about Medicare Supplements (Medigap plans)? Depending on when you’re looking to enroll in a Medigap plan, you may have to undergo a medical underwriting exam. There’s a period where you can enroll in a Medigap plan without needing an underwriting exam. When you become eligible for a Medigap plan, you enter a six-month window called the Medigap Open Enrollment Period. During this time, you can enroll in any Medigap plan and won’t be charged more even if you have a pre-existing condition. However, if you’re outside of your Medigap Open Enrollment Period and do not have a guaranteed issue right, Medicare Supplement carriers can deny your enrollment or charge you more if you have a pre-existing condition.

So, why don’t Medigap plans have to follow the ACA pre-existing condition rules? From what we’ve been able to gather, this is due to these plans offering supplemental coverage. The ACA’s requirements are applicable to plans with minimum essential coverage. Medigap plans offer additional benefits to cover the out-of-pocket costs of Original Medicare, so they don’t meet the minimum essential coverage requirement. This makes enrolling during your Medigap Open Enrollment Period all the more important.

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The good news is that primary forms of Medicare cover pre-existing conditions and cannot charge you more or deny your enrollment if you have these conditions. While Medigap plans may not always have the same protections for those with pre-existing conditions, there are specific times when you can enroll worry-free. In this way, you can ensure that your pre-existing condition isn’t interfering with your health coverage.