Now you’re thinking to yourself, “didn’t the Affordable Care Act (Obamacare) get rid of pre-existing conditions?"
"I thought health insurance companies couldn’t turn you down anymore if you have a pre-existing condition?”
Well, that’s true, but Obamacare and Medicare have different sets of rules. That pre-existing condition rule only applies to Obamacare plans, which are simply individual health plans for folks that are not eligible for Medicare yet.
But, the good news is that Medicare and Medicare plans do offer lots of protections for folks with pre-existing conditions, so let’s take a look at those now…
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Let’s first take a look first at how Original Medicare covers pre-existing conditions. In the next section, we’ll look at how the different Medicare Plans cover them.
So, this section will be short and sweet. Original Medicare cannot turn you down for having any pre-existing condition, and they can’t not cover any of your claims for any of these conditions once Medicare starts for you.
However, Medicare supplemental insurance is a bit different…
Medicare Supplements (Medigap plans)
Let’s break down our look at Medigap plans first by whether they will accept you if you have a pre-existing condition. And then, we’ll look at how they’ll cover those conditions if they do accept you.
Medigap plans do have an approval process when it comes to accepting you based on your health. This approval process is called underwriting. However, if you’re in one of the following situations, they will accept you “no questions asked”:
Medigap Open Enrollment Period (OE) – This is the 6 month period that starts when you’re both 65 or older, and get Medicare Part B for the first time. Both of these conditions have to be true in order for your Medigap Open Enrollment Period to start.
Guaranteed Issue (GI) – There are several situations that will allow you to have guaranteed acceptance into a Medigap plan. These situations are:
- You’re in a Medicare Advantage Plan and the plan is leaving Medicare, stops giving care in your area, or you move out of that plan’s service area
- You already have Medicare and an employer group plan, but that plan is ending
- You already have Medicare and a Medicare SELECT policy, and you move out of that plan’s service area
- You joined a Medicare Advantage plan when you started Part A at 65, and you want to leave that plan and go back to Original Medicare within a 12-month period
- You joined a Medicare Advantage plan for the first time after dropping a Medigap policy, and now you want to switch back to the Medigap plan within a 12-month period. With this situation, you have to go back to the original Medigap plan you have if the company you had before still sells it.
- You lose your Medigap policy through no fault of your own (if your Medigap insurance company goes bankrupt, for example)
- You leave a Medicare Advantage plan or a Medigap plan because the insurance company didn’t follow the rules or misled you
One thing to point out is with GI, you can’t get any Medigap plan you want with “no questions asked”. Only Medigap Plans A, B, C, F, K, or L qualify as GI plans . Only rule #4 above allows you to get any Medigap plan as GI. (see chart below)
So, if you don’t qualify for OE or any of the GI situations, then if you want to enroll in a Medigap Plan, or even switch plans or companies, the new plan can turn you down for pre-existing conditions that you might have. Every insurance company will have their own different list of medical conditions they will base their decision on whether to accept you or not. So, if you have a certain pre-existing condition, it may not prevent you from getting a new Medigap plan, it just might limit your options.
Ok, so that covers actually getting accepted by the plan. But once you’re accepted, do they have to cover you? Not necessarily…
Insurance companies have the right to not cover any medical claims relating to pre-existing conditions for up to 6 months after your policy starts. However, these exceptions to getting your condition covered by your Medigap plan (keep in mind, Original Medicare will still pay their part for treating these conditions), aren’t that common. Here are a few things you can do though to make sure your treatment can’t be denied.
1. Have Continuous “Creditable Coverage”
If you don’t have “creditable coverage” for any period of more than 63 days in the previous 6 months before your Medigap policy starts, your Medigap insurance company has the right to deny claims relating to pre-existing conditions for up to 6 months after the policy starts. So what is “creditable coverage”, here are a few examples:
- Employer group plan
- Medigap Plan
- Medicare Advantage Plan
If you have “creditable coverage”, the new Medigap insurance company cannot refuse to pay these claims.
2. Not Be Diagnosed or Treated During Prior 6 Months
Another way to get your pre-existing condition covered is if you don’t know you have it. If you weren’t diagnosed or treated for this condition during the 6 months before your policy starts (known as the “look-back” period), then the insurance company should have no legal ground to deny your claims relating to this condition.
Another way this rule could apply is if your doctor recommended a possible treatment, or you even had a certain health condition diagnosed or treated, before this “look-back” period. This could likely prevent the insurance company from denying these claims relating to this condition.
3. Have a Guarantee Issue Right
Because every GI right has to do with leaving existing coverage, then you’ve already had “creditable coverage” and can’t have your claims denied.
4. Go With a Medigap Insurance Company Who Will Cover You Anyway
The truth of the matter is that most companies will cover these pre-existing condition claims anyway in the first 6 months of your policy, even though they have the right to refuse them. There is only one insurance company that I know of that has specifically made a statement that they won’t cover these pre-existing claims under the rules mentioned above.
Now this doesn’t mean that other companies won’t deny your claims, or that they won’t start in the near future. But I have hundreds of clients and have not heard once from any of my clients that they haven’t been covered in this situation. You should still do your due diligence when it comes to making sure you’re covered under these situations, but I personally haven’t experienced this issue. Take that for what it’s worth.
Medicare Advantage Plans
The only pre-existing condition a Medicare Advantage Plan can turn you down for is End Stage Renal Disease (ESRD). However, even if you have ESRD, you can still join a Medicare Advantage Plan in certain situations. Also, these plans cannot turn down claims for pre-existing conditions either. Pretty straightforward, huh?
So this has been pretty comprehensive discussion of your rights to get covered with your pre-existing condition under Medicare. Hopefully this answers any questions you might have on this topic. If you’d like any help finding a Medigap plan that covers your pre-existing condition, I’d love to help. Every insurance company has its own set of rules for what conditions they’ll accept, so let me shop for you in finding a better rate based on your unique situation. I’m licensed with over a dozen different insurance companies and can hopefully find one that’ll be a good fit for you.