Medicare and preexisting condition waiting periods

Medical News Today

02-06-2025

Original Medicare and Part C plans cannot deny coverage based on preexisting conditions. However, a waiting period for enrolling in Medicare due to preexisting conditions can apply to a Medigap plan.
Due to the Affordable Care Act (ACA), Original Medicare (parts A and B), Medicare Advantage (Part C), and Part D drug plans cannot impose waiting periods for preexisting conditions or deny coverage based on such conditions.
However, Medicare supplement (Medigap) plans are not subject to the ACA. For this reason, people who wish to sign up for a Medigap plan should be aware of enrollment and waiting periods where preexisting conditions might be applicable. Medigap initial enrollment period
Private companies approved by Medicare offer Medigap plans, which are also called Medicare supplement plans. These plans cover costs that Original Medicare does not cover, such as deductibles, coinsurance, and copayments.
Since Medigap plans do not provide direct medical coverage and do not meet the ACA's minimum essential coverage requirements, insurers can deny coverage due to preexisting conditions. However, other federal laws impose certain restrictions, one of which applies during the initial enrollment period.
When a person turns 65 and enrolls in Medicare Part B, they enter a six-month Medigap open enrollment period. During this time, they can choose any Medigap policy without undergoing medical underwriting. Insurers cannot deny them coverage based on preexisting conditions, allowing the person to select the plan that best fits their needs.
If a person misses this enrollment period, they may face higher costs or experience coverage denial. Additionally, those under 65 who qualify for Medicare due to a disability might have to wait until they reach 65 before Medigap insurers must legally offer them coverage. » Learn moreDoes Medicare cover preexisting conditions?
Insurance companies can refuse to enroll a person in a Medigap plan based on preexisting conditions if the person applies outside the initial 6-month enrollment window.
However, exceptions exist in which a person can get protection from coverage denial even after this period ends. These exceptions, called 'guaranteed issue rights,' apply in the following specific circumstances:
A Medicare Advantage Plan either changes, becomes unavailable in the person's area, or the person moves outside its service zone.
A person with Original Medicare and an employer or union plan that offers coverage after Medicare, including the Consolidated Omnibus Budget Reconciliation Act (COBRA), loses that coverage.
A person with Original Medicare and a Medicare SELECT policy moves out of the policy's service area.
A person who initially joined a Medicare Advantage Plan or Programs of All-Inclusive Care for the Elderly (PACE) when they first became eligible for Medicare decides to switch to Original Medicare within the first year.
A person who switched to a Medicare Advantage Plan (or Medicare SELECT) within the past year now wants to switch again.
A person's Medigap insurance provider goes bankrupt or cancels a person's policy through no fault.
A person changes or cancels their Medicare Advantage plan or Medigap policy due to a violation or misleading information from the provider.
Additionally, some states may have additional 'guaranteed rights' beyond what federal regulations require. » Learn more:What to know about Guaranteed Issue in Medicare
Ten Medigap plans offer different levels of coverage. A person who has held their current Medigap policy for more than 6 months and wants to switch to the same Medigap plan offered by another insurance plan cannot experience coverage denial based on preexisting conditions, nor do they have to wait for coverage.
But if a person wants to switch between different Medigap plans, they may have to wait 6 months for coverage. This is known as the preexisting condition waiting period.
However, their new insurer should account for the period when the person has had coverage from their existing Medigap plan. For example, if a person has had 2 months of coverage before switching, their new policy should only impose an additional 4-month wait. Medicare Advantage trial period
Medicare Advantage (Part C) plans must offer coverage equivalent to Original Medicare (parts A and B). According to the ACA, insurers providing Part C plans cannot deny coverage based on preexisting conditions.
However, since a person can only have Medigap for Original Medicare expenses, they must discontinue their Medigap plan if they choose a Part C plan.
For this reason, Medicare grants a 12-month trial period to allow a person to test a Part C plan without losing their Medigap coverage. The person may leave the Part C plan and return to Original Medicare within this period. In that case, they can rejoin their previous Medigap plan or select a new one without medical underwriting.
Original Medicare (parts A and B), Medicare Advantage (Part C), and Part D prescription plans have no preexisting conditions waiting periods. This means these plans cannot deny coverage because of preexisting conditions.
However, specific enrollment and waiting periods for preexisting conditions might apply to a Medicare supplement (Medigap) plan. These include a 6-month initial enrollment period, guaranteed issue rights, and a 12-month trial period to test a Part C plan.
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