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.

Outside Open Enrollment

If you apply for Medigap coverage after your open enrollment period, there’s no guarantee that an insurance company will sell you a Medigap policy if you don’t meet the medical underwriting requirements, unless you’re eligible due to one of the situations below.

In some states, you may be able to buy another type of Medigap policy called Medicare SELECT. If you buy a Medigap SELECT policy, you have rights to change your mind within 12 months and switch to a standard Medigap policy.

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 leave a Medicare Advantage Plan or drop a Medigap policy because the company hasn’t followed the rules, or it misled you.