What are considered “Pre-Existing Conditions?”
A health problem, like asthma, diabetes, or cancer, you had before the date that new health coverage starts. Insurance companies can’t refuse to cover treatment for your pre-existing condition or charge you more.
Under current law, health insurance companies can’t refuse to cover you or charge you more just because you have a “pre-existing condition” — that is, a health problem you had before the date that new health coverage starts.
The following examples may be considered as pre-existing conditions when you’re applying for a Medicare Supplement plan, (or Medigap):
- You had a heart attack 12 years ago
- You use an inhaler as needed for asthma
- Your doctor has recommended cataract surgery in the future
- You have arthritis
- You’re receiving treatment for cancer
As you can see, that’s quite a range of situations; a pre-existing condition does not necessarily need to be a grave diagnosis.
When a pre-existing condition can NOT be used against you
Medical underwriting is the process in which insurers consider health history (including pre-existing conditions) when making judgments on who is accepted into a health-care plan and how much they will pay. Medicare Supplement plans are sold by private health insurance companies which usually are allowed to use medical underwriting when evaluating insurance applications. One period in which insurers cannot use medical underwriting when considering your application is during your Medicare Supplement Open Enrollment Period.
This period lasts for six months and begins on the first day of the month in which you’re both 65 or older and enrolled in Medicare Part B. During your Medicare Supplement Open Enrollment Period, an insurance company can NOT refuse to sell you a policy based on your pre-existing condition, and it can’t charge you more than someone without health problems. After your Open Enrollment Period ends, you may be subject to medical underwriting.
The pre-existing condition waiting period
Generally, if you enroll in a Medicare Supplement plan during your Medicare Supplement Open Enrollment Period, the insurance company can NOT make you wait for your coverage to start. However, sometimes you may be subjected to a “pre-existing condition waiting period.” This means that you may have to pay all your own out-of-pocket costs for your pre-existing condition for up to six months. After the waiting period, the Medicare Supplement insurance plan may cover Medicare out-of-pocket costs relating to the pre-existing condition.
You might be able to avoid or shorten the pre-existing condition waiting period if you had at least six months of creditable coverage before applying for the Medicare Supplement plan. Creditable coverage could be individual health insurance, group health insurance (such as from an employer), TRICARE (military retiree benefits), and more. If you’re replacing your creditable coverage with a Medicare Supplement insurance plan, the insurance company generally can’t make you wait before it covers your pre-existing conditions.
Original Medicare (Part A and Part B) doesn’t have the same waiting period that some Medicare Supplement insurance plans have. Original Medicare may cover a condition even when your Medicare Supplement insurance plan won’t, but you might be responsible for coinsurance or copayment.
What might not be covered?
All Medicare Supplement plans cover Medicare Part A (hospital insurance) coinsurance for up to 365 days after Medicare benefits are used up. If you are in a pre-existing condition waiting period and you are hospitalized for a car accident, which is not a pre-existing condition for you, your Medicare Supplement plan may cover your hospital coinsurance.
However, for example, if you are in a pre-existing condition waiting period and you are hospitalized for an asthma-related health problem and asthma is a pre-existing condition for you, you may have to pay your hospital coinsurance out-of-pocket. Original Medicare may still pay a portion of your hospital costs.