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Medigap Coverage with Pre-Existing Conditions

Pre-existing conditions are health issues that a person has prior to enrolling in a new health insurance policy. The conditions can range from high blood pressure to cancer. Having a pre-existing condition could affect your Medigap coverage, but there are protections in place for Medicare beneficiaries if they apply during a specific period.

The open enrollment period is the best time to purchase Medigap coverage because insurance providers cannot legally deny a person coverage or increase the premiums due to a pre-existing condition. During this enrollment period, insurers cannot deny a beneficiary coverage but their medical costs could increase because of a waiting period.

Waiting Period

Some Medigap applicants with pre-existing conditions may face a waiting period. Although coverage cannot be denied outright during the open enrollment period, insurers can refuse to cover the out-of-pocket costs for the pre-existing condition for up to 6 months. Insurance providers can only impose this waiting period if the pre-existing condition was treated or diagnosed in the six months prior to starting Medigap coverage.

If this occurs, Original Medicare will still cover the condition but the out-of-pocket costs will not be covered including co-payments and co-insurance expenses. Treatments that are unrelated to the pre-existing condition will still be covered by Medigap during this time. After the 6 month waiting period, the Medigap policy will cover the condition as pre-determined by the chosen standardized plan.

For those with a guaranteed issue right, Medigap insurance companies cannot place any kind of waiting period for pre-existing conditions.

Credible Coverage Reduces Impact of Waiting Period 

One way to help offset the negative financial effect of the waiting period is through credible coverage. Medicare beneficiaries could qualify for coverage if the following statements are true:

  • You had at least 6 months worth of continuous health coverage before enrolling in Medigap
  • You did not have a break in coverage for more than 63 days during that period
  • The type of health coverage you had qualifies as creditable coverage

Your insurer will be able to determine if your previous coverage counts as creditable coverage.


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