What if I Have Pre-Existing Conditions?

Medicare is the Federal health insurance program originally passed into law in 1965 to provide coverage for citizens and legal residents age 65 or over. Later the law was modified to allow coverage for disabled individuals under 65, and for people with End Stage Renal Disease (ESRD). Once in the Medicare program, you are covered for any past or present medical or health condition. Prior to Medicare you may have suffered from preexisting condition coverage exclusions, but those will not and cannot apply once you enroll into Medicare.

With Original Medicare, there are no pre-existing conditions.

What About Private, Medicare Advantage Plans?

Again, the answer is “no,” but with one exception. If you have ESRD, otherwise known as kidney failure, you can be denied enrollment into an Advantage Plan. However, having said that, there are some Medicare Advantage Special Needs Plans who do accept ESRD patients. But even if you do have ESRD, you are still covered under the federally managed Original Medicare program.

What About Medicare Supplement Plans?

Buy a Policy When You’re First Eligible

The best time to buy a Medigap policy is during your 6-month Medigap open enrollment period, because you can buy any Medigap policy sold in your state, even if you have health problems. This period automatically starts the month you’re 65 and enrolled in Medicare Part B, and once it’s over, you can’t get it again.

During Open Enrollment

Medigap insurance companies are generally allowed to use medical underwriting to decide whether to accept your application and how much to charge you for the Medigap policy. However, if you apply during your Medigap open enrollment period, you can buy any Medigap policy the company sells, even if you have health problems, for the same price as people with good health.

Guaranteed Issue Rights?

Guaranteed issue rights (also called “Medigap Protections“) are rights you have in certain situations when insurance companies must offer you certain Medigap policies. In these situations, an insurance company:

• Must sell you a Medigap policy
• Must cover all your pre-existing health conditions
• Can’t charge you more for a Medigap policy because of past or present health problems

In most cases, you have a guaranteed issue right when you have other health coverage that changes in some way, like when you lose the other health care coverage. In other cases, you have a “trial right” to try a Medicare Advantage Plan (Part C) and still buy a Medigap policy if you change your mind.

You have a guaranteed issue right in these situations:

  • You’re in a Medicare Advantage Plan, and your plan is leaving Medicare or stops giving care in your area, or you move out of the plan’s service area.
  • You have Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.
  • You have Original Medicare and a Medicare SELECT policy. You move out of the Medicare SELECT policy’s service area.
  • You joined a Medicare Advantage Plan or Programs of All-inclusive Care for the Elderly (PACE) when you were first eligible for Medicare Part A at 65, and within the first year of joining, you decide you want to switch to Original Medicare. (Trial Right)
  • You dropped a Medigap policy to join a Medicare Advantage Plan (or to switch to a Medicare SELECT policy) for the first time, you’ve been in the plan less than a year, and you want to switch back. (Trial Right)
  • Your Medigap insurance company goes bankrupt and you lose your coverage, or your Medigap policy coverage otherwise ends through no fault of your own.
  • You leave a Medicare Advantage Plan or drop a Medigap policy because the company hasn’t followed the rules, or it misled you.


Medicare Planning Checklist

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