A pre-existing condition is a medical condition that started before a person’s health benefits went into effect (like diabetes, COPD, cancer, sleep apnea, etc.) Some of the most common questions we get are, “Do pre-existing conditions impact your Original Medicare coverage? What is considered a pre-existing condition? How do Medigap and pre-existing conditions work?”
Original Medicare and Pre-Existing Conditions
Before we dive into Medigap and pre-existing conditions, let’s discuss the role of Original Medicare. A pre-existing condition cannot stop you from enrolling in parts A and B, and you will not be charged more due to your condition. This is great news for those who have been previously diagnosed with asthma, diabetes, cancer, or some other chronic health condition. However, your out-of-pocket costs can quickly add up if you’re only enrolled in Original Medicare. Fortunately, Medicare Supplements can help!
What are Medicare Supplements?
The average beneficiary enrolled in Original Medicare spends roughly $4,300 each year on premiums, deductibles, copayments, and other Medicare-related costs. Medicare Supplement (Medigap) plans can be purchased to work alongside Original Medicare to help cover these costs and provide financial protection through a range of benefits. These benefits include:
- Blood work copays (up to three pints)
- Foreign emergency travel
- Hospice coinsurance and copayments
- Part A coinsurance and hospital costs
- Part A deductible
- Part B coinsurance and copayments
- Part B deductible
- Part B excess charges
- Skilled nursing facility coinsurance
There are ten different types of Medigap plans that you can choose from, and each plan offers a different combination of benefits. Generally, the more benefits a plan has, the higher the monthly premium will be. Medigap plans do not replace Original Medicare, and you must be enrolled in parts A and B first.
Popular Medigap Plans
The most popular Medigap plans are generally the ones that offer the most comprehensive coverage. They typically have higher monthly premiums, but they help you save money in the long-run. These plans include:
Plan F and Plan C are going away in 2020. They are the only two plans that cover your Part B deductible. Congress believed that covering the Part B deductible made the plan too inclusive, and people were encouraged to visit the doctor too often because it was practically free. If this specific benefit is important to you, you need to enroll before 2020. To get started, click here or call 833-438-3676.
Medicare Advantage vs. Medicare Supplements: How Pre-existing Conditions Affect Each Option
Medicare Advantage and Medicare Supplements are two very different types of plans. Medicare Advantage plans are stand-alone plans that offer the same benefits as Original Medicare. These plans often include extra health benefits like hearing, vision, dental, or group fitness classes (like SilverSneakers and Silver & Fit). Medicare Supplement (Medigap) plans offer financial protection but usually do not include additional health benefits. You cannot be enrolled in a Medicare Advantage and Medicare Supplement plan at the same time. If you aren’t sure which type of plan is best for you, one of our licensed agents can help! To get started, click here or call 833-438-3676.
Medigap Plans Eligibility
To be eligible for a Medigap plan, you must be enrolled in parts A and B first. Medicare Supplements are sold through private insurance companies. However, states are not required to sell Medigap plans to beneficiaries under 65. This means if you qualified for Medicare through ESRD (end-stage renal disease), ALS (Lou Gehrig’s disease), or SSDI (Social Security Disability Income) and are not yet 65, you can be denied a Medigap plan.
Medicare Supplements for Beneficiaries Under 65
Some Medigap plan carriers do offer plans to beneficiaries under 65, but they may charge more, impose waiting periods, or deny coverage for pre-existing conditions. However, if you can’t get a reasonably priced Medigap plan, there are hundreds of disabilities that are automatic qualifiers for Medicare Advantage Chronic Special Needs Plans. You do not have to be 65 to qualify for these plans as long as your disability is a qualifier.
When Can I Buy Medigap?
If you apply for a Medigap plan, you have certain rights guaranteed by federal law. These are called “guaranteed issue rights,” and they protect you from being denied healthcare. During your Initial Enrollment Period (IEP), you cannot be overcharged or denied access to Medigap based on pre-existing conditions.
You can purchase a Medigap plan year-around, but if you do not purchase a Medigap plan during your IEP, you can be denied coverage or required to pay a higher premium. This occurs through medical underwriting where the insurer can consider your age, gender, and pre-existing conditions you have been diagnosed with or treated for in the last six months. Plus, some insurers can refuse to cover your pre-existing condition for up to six months. This is called your waiting period. This can be avoided or shortened if you have had creditable health coverage. Insurers classify creditable health coverage to be any form of healthcare that has been active for at least 63 consecutive days.
Medigap Plan Finder
If a Medigap plan is something that sounds interesting to you, your best Medigap plan finder tool is a licensed agent! Our licensed agents are contracted with all of the major plans and carriers to eliminate any bias when showing you plan availability and costs. If you’re interested in speaking with a licensed agent or setting up an appointment, click here or call 833-438-3676.
This blog was originally published on 10/28/18, but was updated on 6/14/19.