Does Medicare Cover Pre-Existing Conditions?
Typically, Original Medicare (Part A and Part B) does cover pre-existing conditions.
Medicare Supplement Insurance (Medigap) policy providers may deny you coverage or charge higher premiums based on your health if you don't buy your policy during your Medigap open enrollment period.
Medicare Advantage plan carriers don't use pre-existing conditions as a consideration when you apply for a plan, unless you have end-stage renal disease (ESRD).
Original Medicare Covers Pre-Existing Conditions
A pre-existing condition is defined as any health issue or disability that you had prior to signing up for a health insurance policy. With Original Medicare, you can't be denied coverage for pre-existing conditions.
Original Medicare consists of Medicare Part A and Medicare Part B.
Medicare Part A covers:
Skilled nursing family care
Nursing home care
Home health services
Medicare Part B covers:
Services and supplies needed to diagnose or treat an illness or condition — typically outpatient services like doctor's visits
Do Medicare Advantage Plans Cover Pre-Existing Conditions?
Medicare Advantage (Medicare Part C) plans are an alternative to Original Medicare that allow you to receive your Part A and Part B benefits from a private health insurance company.
Most Medicare Advantage plans cover preexisting conditions, unless you have ESRD. If you have ESRD or another chronic condition, you may qualify for a Medicare Special Needs Plan (SNP), if one is available in your area.
Medicare Advantage plans can also include additional benefits, such as dental, vision and prescription drug coverage.
Your Medicare Advantage plan may also include out-of-pocket expenses such as copayments and deductibles. You cannot have a Medigap plan and a Medicare Advantage plan at the same time.
Pre-Existing Conditions and Medicare Supplement Insurance
Medigap plans, also known as Medicare Supplement Insurance, are sold by private insurers.
Medigap plans help pay for some of the out-of-pocket costs associated with Original Medicare. These can include copayments, coinsurance and deductibles and some additional expenses.
Medicare Supplement Insurance plans will offer you benefits even if you have a pre-existing condition, as long as you buy your plan during your Medigap open enrollment period.
Your open enrollment period only lasts for six months and starts as soon as you are both:
- At least 65 years old
- Enrolled in Medicare Part B
During your Medigap open enrollment period, insurers cannot deny you coverage or charge more for a Medigap policy based on any pre-existing conditions you may have.
There are 10 standardized Medigap plans that are sold by private insurance companies in most states (Massachusetts, Minnesota and Wisconsin have different options). Availability and cost can vary by state.
The plans are standardized, offering at least the following same basic benefits:
Part A coinsurance for hospital care
Part A coinsurance or copayment for hospice care
Part B coinsurance or copayment
The first three pints of blood
The plan options then each offer a different combination of additional benefits. Compare each Medigap plan type below.
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Medicare Supplement Benefits
Part A coinsurance and hospital coverage
Part B coinsurance or copayment
Part A hospice care coinsurance or copayment
First 3 pints of blood
Skilled nursing facility coinsurance
Part A deductible
Part B deductible
Part B excess charges
Foreign travel emergency
* Plan F and Plan C are not available to Medicare beneficiaries who became eligible for Medicare on or after January 1, 2020. If you became eligible for Medicare before 2020, you may still be able to enroll in Plan F or Plan C as long as they are available in your area.+ Read more
1 Plans F and G offer high-deductible plans that each have an annual deductible of $2,370 in 2021. Once the annual deductible is met, the plan pays 100% of covered services for the rest of the year. The high-deductible Plan F is not available to new beneficiaries who became eligible for Medicare on or after January 1, 2020.
2 Plan K has an out-of-pocket yearly limit of $6,220 in 2021. After you pay the out-of-pocket yearly limit and yearly Part B deductible, it pays 100% of covered services for the rest of the calendar year.
3 Plan L has an out-of-pocket yearly limit of $3,110 in 2021. After you pay the out-of-pocket yearly limit and yearly Part B deductible, it pays 100% of covered services for the rest of the calendar year.
4 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to $50 copayment for emergency room visits that don’t result in an inpatient admission.- Read less
Learn more about common procedures that medicare covers.
Find Medicare Supplement Plans in Your Area
A licensed agent can help you decide on a Medicare option that works for you. Call today to speak with a licensed agent and compare the Medigap plans that are available where you live.
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Christian Worstell is a health care and policy writer for MedicareSupplement.com. He has written hundreds of articles helping people better understand their Medicare coverage options.