Do you have a pre-existing condition?

Buying a Medicare Supplement plan when you have pre-existing medical conditions

Buying a Medicare Supplement plan when you have pre-existing medical conditions is a concern and can complicate the application process.  The best time to purchase a Medicare Supplement (also known as “Medigap”) plan when you have a pre-existing condition is during the Medicare Supplement Open Enrollment Period.  This period lasts for six months and begins the first day of the month when you turn 65 years of age and and enrolled in original Medicare Part A and Part B.  During this period, an insurance company cannot make you wait for coverage to begin or charge you a higher premium for pre-existing condition.  If you are changing your Medicare Supplement policy the insurance company is required by law to offer a policy, cannot charge a higher premium, and must cover any pre-existing conditions during the Medicare beneficiary’s Medicare Supplement Open Enrollment Period.

Buying a Medicare Supplement plan when you have pre-existing conditions outside of the Medicare Supplement Open Enrollment Period

Buying a Medicare Supplement plan when you have pre-existing conditions outside of a Medicare Supplement Open Enrollment Period is not impossible, but it is more complicated.  There are other Medicare Supplement Enrollment Periods other than during your Initial Enrollment Period for original Medicare; however, these enrollment periods are few and far between in most states.  Purchasing a Medicare Supplement plan outside of the Open Enrollment Period requires the Medicare beneficiary to answer health questions and go through the underwriting process.  It is important to note that Medicare Supplement policies can be written at any time during the year and are not restricted to and should not be confused with the Annual Election Period.  Federal regulations allow insurance companies to deny, or avoid, paying claims associated with pre-existing conditions not to exceed the first six months that their Medicare Supplement plans are in-force.  This is called the “waiting period for pre-existing conditions” and is also a part of the underwriting process.  If any condition has been either diagnosed or treated during the six months prior to the effective date of the Medicare Supplement policy the insurance company can refuse to pay for any services related to that condition. However, after six months of insuring the Medicare beneficiary the insurance company must pay for the same conditions as it would for any hospital or medical claim.

Do I really need to be concerned about waiting periods for pre-existing conditions?

Attempting to purchase a Medicare Supplement plan when you have pre-existing medical conditions and you are outside of the Medicare Supplement Open Enrollment Period may result in denial of the Medicare beneficiary’s application if the medical condition is considered disqualifying health condition.  Waiting periods for coverage of pre-existing conditions is usually not an issue with Medicare Supplement policies.  It is important to note, however, that a pre-existing medical condition that is considered a disqualifying medical condition by one insurance company may not be considered as a disqualifying medical condition by another insurance company.  Additionally, not all insurance companies that sell Medicare Supplement policies deny applications based on pre-existing conditions.  Instead, they impose the “waiting period for pre-existing conditions.”  Obviously the insurance companies which have no waiting periods emphasize their greater willingness to pay the claims of those who need treatment the moment they enroll in a Medicare Supplement plan.

When buying a Medicare Supplement plan when you have pre-existing medical conditions look for a “waiting period” exclusion

Typically, when buying a Medicare Supplement plan when you have pre-existing medical conditions is not a significant issue and the “waiting period for pre-existing conditions” is not typically utilized by the insurance company.  However, if a pre-existing condition concerns you and you are shopping for a new Medicare Supplement policy, pay close attention to the application and any language regarding a waiting period.  Specifically, if you are replacing any type of health insurance coverage with a Medicare Supplement policy the law states that you must be provided with a Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage.  This Notice of Replacement identifies the purpose of termination of your prior coverage.  The language contained in the Notice of Replacement regarding pre-existing conditions or waiting periods must include the following:

1.  If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing pre-existing condition limitations, please skip to
statement 2 below. Health conditions that you may presently have (pre-existing conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

2.  State law requires that your replacement policy or certificate may not contain new pre-existing conditions, waiting periods, elimination periods or probationary periods. The insurer will waive any time periods applicable to pre-existing conditions, waiting periods, elimination periods, or probationary periods in the new policy (or coverage) for similar benefits to the extent such time was spent (depleted) under the original policy.

However, Paragraphs 1 and 2 of the Replacement Notice (applicable to pre-existing conditions) may be deleted by an issuer if the replacement does not involve application of a new pre-existing condition limitation.

When buying a Medicare Supplement plan when you have pre-existing medical conditions, is there a way of avoiding any “waiting periods”?

You can avoid waiting periods for pre-existing conditions if you have had continuous creditable coverage, or have not went without health care coverage for a period of more than 63 days, prior to the effective date of the Medicare Supplement policy.  In other words, if you had been covered by an employer-sponsored plan for four months before the effective date of your Medicare Supplement policy, the insurance company issuing the Medicare Supplement policy has a six-month waiting period, you will be credited with four months, so you will have only two more months to wait for the pre-existing condition to be covered. This is based upon the fact that the employer-sponsored plan is considered “creditable coverage”.   The same applies if you had creditable coverage for six months prior to the effective date of the Medicare Supplement policy except there would be no waiting period because the six months waiting period has been satisfied.

What is considered creditable coverage which will shorten or eliminate a “waiting period” for pre-existing conditions?

Almost any kind of health coverage can be creditable coverage.  Specifically, the following is considered creditable coverage:

  • an individual or group policy
  • Medicare Part A or Part B
  • Medicaid
  • medical programs of Indian Health Services and tribal organizations
  • state health benefits risk pools
  • insurance through the Peace Corps Act
  • any public health plan

Medicare Pathways will assist you in finding a Medicare Supplement plan and avoid any  “waiting period for pre-existing conditions”.  Medicare Pathways Benefit Advisors work with over 20 different insurance companies which allows them to shop and not only find a more affordable and/or more appropriate plan, but also to review the health questions on the applications for the numerous insurance companies and and take your medical history into consideration before preparing the application.  A Medicare Pathways Benefit Advisor will not encourage you to apply for a Medicare Supplement plan if it is clear that you are not eligible and your application will subsequently be denied due to pre-existing medical conditions.  Medicare Pathways Benefit Advisors are highly trained and can review your individual situation and determine if you may have a guaranteed issue period based on certain circumstances that have occurred in your life, or if the state you reside in has certain Open Enrollment Periods that are unique to that state.   It is important not to cancel your current coverage until you know your application for a new policy has been approved.

Let a Medicare Pathways Benefit Advisor assist you in making the most of your Medicare.  You can call 1-866-466-9118, or you can click Request a Quote . Give us a call at Medicare Pathways for more information at 1-866-466-9118.