Original Medicare (Medicare Part A and Medicare Part B) will never deny your Medicare benefits, regardless of your prior medical conditions. However, if you’re considering a Medicare Supplement insurance policy (sometimes called Medigap), you should be aware that your preexisting conditions may delay some Medigap benefits for up to 6 months. This is called the Medicare Supplement Waiting Period.
Most people have a chance to avoid the Medicare Supplement Waiting Period entirely. It won’t impact new medical conditions or your Original Medicare benefits.
What’s a Pre-Existing Condition?
If you have a pre-existing medical condition, you’re not alone. According to an analysis by the Department of Health and Human Services, up to half of Americans under age 65 already have some type of pre-existing health condition (in this case, a health issue that developed before your Medicare Supplement start date).
Unfortunately, there’s no cut-and-dry list of what does or does not qualify as a pre existing condition that may prevent you from getting coverage. The criteria can vary from plan to plan. You can assume that any physical or mental injury, illness, disorder, ailment or disease that was diagnosed before the start of a new policy may count.
What is the Medicare Supplement Waiting Period?
For up to six months after your Medicare Supplement begins, your new plan can choose not to cover its portion of payments for pre-existing conditions. This forces you to pay out of pocket for standard Medicare costs like Medicare Part B’s 20 percent coinsurance. Once 6 months expire, the plan will work without hassle.
Fortunately, keep in mind that:
- Medicare Supplement plans must continue to cover medical costs for new ailments and injuries during your waiting period.
- Original Medicare does not have waiting periods for pre-existing conditions.
- Even if you are subject to a Medigap waiting period due to your previous medical history, your Medicare plan will still cover its portion of care for your pre-existing condition during this time. And after 6 months, your Medicare Supplement will kick in as well.
- Most people will not have any waiting period (read more below).
In most states, Medicare Supplement plans can ask about your pre-existing conditions if you don’t sign up during your Medigap Open Enrollment Period. When you sign up for a Medicare Supplement plan after this period ends, things can get a little tricky. If you have a pre-existing condition, insurance companies are legally allowed to:
- Refuse to sell you a Medicare Supplement plan
- Subject you to a pre-existing condition waiting period for up to six months of your policy
- Charge you a higher premium than someone new to Medicare would be responsible for
- This is called medical underwriting – that is, a higher price due to your health conditions.
Avoiding the Medicare Supplement Waiting Period for Pre-Existing Conditions
There’s a good chance that you won’t have a Medicare Supplement Waiting Period. Here’s why:
Your Recent Insurance: By law, Medicare Supplement plans must shorten any pre-existing condition waiting period by the number of months you had creditable coverage directly leading up to your enrollment. Fortunately, most forms of health insurance are considered to be creditable.
If you were covered under a group or individual insurance plan, chances are it met the criteria. Some exceptions to creditable coverage are short-term plans, being uninsured, or only using Original Medicare.
Your creditable coverage grants you a one-for-one exchange for up to six months. This means your pre-existing condition waiting period is reduced for one month for each month you were enrolled in creditable coverage prior to signing up for your Medicare Supplement plan.
So, if you had creditable coverage for four months before enrolling, you may only have a two month waiting period imposed on your plan.
If you maintained six or more months of prior creditable coverage, Medicare Supplement providers must cover all your pre-existing medical conditions. However, if you lost creditable coverage more than 63 days before getting Medicare Supplement, then creditable coverage will no longer apply.
Your Initial Signup Period Helps: The best way to avoid issues with Medicare Supplement and pre-existing conditions is to sign up for your policy soon after you get Medicare. You can apply for Medicare Supplement plans at any time, but your guaranteed enrollment period lasts for six months. It starts on the first day of the month you’re both 65 or older and are also enrolled in Medicare Part B. Medigap doesn’t have annual enrollment periods, so instead your open window to apply is specific to you.
During your six month Medigap Open Enrollment Period, Medigap policies cannot deny your application or vary their premiums based on your health status. They can still put a waiting period in place for a pre-existing condition for a maximum of six months, but the period can be eliminated or drastically shortened. You may be able to confirm specific conditions that will be excluded in the final stage of your application.
Switching Medicare Supplement Plans: If you successfully switch between Medicare Supplement plans, then your new plan cannot exclude coverage for any pre-existing conditions.
Under 65 Years Old: If you get Medicare before your 65th birthday, most states do not guaranteed enrollment into a Medigap plan. If you are accepted into a plan, the maximum possible waiting period is the same.
Special Enrollment Exceptions to the Pre-Existing Waiting Period Rule
After your initial Medigap enrollment window closes, you can be declined or charged more for your plan based on your pre-existing conditions and medical history. So, if you switch Medicare Supplement plans, do you still have a waiting period? Maybe not.
There are certain situations that allow for an exception to the waiting period rule. This includes (but is not limited to):
- You move out of your Medicare Advantage plan’s area
- Your Medicare Advantage plan has been discontinued or is leaving your service area
- You lose your Medicare Supplement insurance plan because the insurance company went bankrupt
- You end your Medigap coverage because the insurance company misled you or was not compliant with the law
- You’ve had your Medicare Advantage or PACE plan for less than a year and want to sample another plan
- You have Medicare Advantage or Medicare SELECT and (for the first time) want to switch back to Medigap
- You live in a state with its own exceptions (New York, Connecticut, California, Maine, Missouri, Oregon or Washington, in some circumstances)
If you meet the criteria for any of the exceptions, you’ll be automatically granted a Medicare Supplement Special Enrollment period This helps you avoid expensive underwriting, and you won’t be subject to a pre-existing condition waiting period.
Your Next Steps with Medicare Supplement
It’s important to get Medicare Supplement sooner rather than later. This is especially true if you have a known pre-existing condition. It’s the best way to avoid a waiting period and to ensure you get the coverage you want.
If you’re looking for Medicare Supplement insurance outside of your Medigap open enrollment window, you still have options.
Different companies may have lower prices or easier enrollment guidelines. So while one company may deny coverage for your pre-existing condition, a broker can guide you to others that won’t. Call HealthCare.com today to be connected to an independent, locally-licensed agent who can help.
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