Do Medicare Supplement Plans Cover Pre-Existing Conditions?

Understanding Medigap and Pre-Existing Conditions

Medicare Supplement Plans, often called Medigap, are private insurance policies designed to work alongside Original Medicare (Parts A and B). These plans help cover certain out-of-pocket costs that Original Medicare does not, such as deductibles, copayments, and coinsurance. Medigap policies standardize their benefits, meaning a Plan G from one insurer offers the same basic benefits as a Plan G from another.

A “pre-existing condition” refers to a health issue for which you received diagnosis or treatment before your new insurance coverage began. Original Medicare (Parts A and B) covers pre-existing conditions without any waiting periods or additional costs.

Medigap plans help with the cost-sharing responsibilities for services covered by Original Medicare. The interaction between Medigap plans and pre-existing conditions involves specific rules regarding waiting periods and enrollment timing.

Medigap Coverage for Existing Health Issues

Medigap plans generally cover pre-existing conditions, but a waiting period may apply depending on when you enroll. If you apply for a Medigap policy outside of specific enrollment windows, insurers may impose a pre-existing condition waiting period of up to six months. During this period, the Medigap policy might not cover out-of-pocket costs related to a pre-existing condition.

This waiting period applies if you were diagnosed with or treated for a condition within six months before your Medigap policy’s effective date. After the waiting period concludes, the Medigap plan will begin paying its share of costs for that pre-existing condition, provided Original Medicare covers the service.

If you had prior continuous health coverage, known as “creditable coverage,” for at least six months before your Medigap policy started, this can reduce or eliminate the waiting period. Each month of creditable coverage shortens the waiting period by one month. However, a break in coverage of more than 63 days generally prevents creditable coverage from being used to reduce the waiting period.

Special Enrollment Rights

The most advantageous time to enroll is during your Medigap Open Enrollment Period, which is a six-month window beginning the first month you are both 65 or older and enrolled in Medicare Part B. During this period, insurers cannot deny you a Medigap policy, charge you more due to health issues, or impose a waiting period for pre-existing conditions.

Beyond the initial Open Enrollment Period, “Guaranteed Issue Rights” provide specific situations where you can buy a Medigap policy without medical underwriting. These rights ensure that insurers cannot refuse coverage or impose a pre-existing condition waiting period, even if you have health problems. Examples of situations that trigger guaranteed issue rights include losing employer-sponsored health coverage, your Medicare Advantage plan leaving your service area, or your Medicare Advantage plan ceasing to offer services.

These rights are crucial because they offer a pathway to secure a Medigap policy without fear of denial or a waiting period for pre-existing conditions. If you qualify for a guaranteed issue right, the insurer must offer you certain Medigap plans, typically Plan A, B, C, F, K, L, M, and N, or the most popular plans in your area, and cannot consider your health status.

Enrolling in a Medigap Plan

You can begin by comparing the various standardized Medigap plans, such as Plan G or Plan N, to determine which best fits your healthcare needs and budget. Each plan type offers a different set of benefits, so reviewing these options is a necessary part of the selection process.

To purchase a Medigap policy, you will typically contact private insurance companies that offer these plans in your area. They can provide quotes and detailed information about their specific offerings. When you are ready to apply, you will need to provide essential information, including your Medicare number and the effective dates for both your Medicare Part A and Part B coverage.

The application process usually involves completing a form and, depending on your enrollment circumstances, may include health questions if you are outside of a guaranteed issue period. Once your application is submitted and approved, the insurance company will provide you with your policy details and effective date.