How Does Medicare Insurance Handle Pre-existing Conditions?

Janell Sluga Medicare & Individual Health Insurance Account Executive View Bio

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Question:

I am turning 65 later this year, how will Medicare handle the coverage of my already existing medical problems?

Answer:

Congratulations on reaching Medicare eligibility! Your coverage with Medicare is very comprehensive. When you become Medicare eligible, Medicare covers all your pre-existing medical conditions with very few exceptions. If you have Diabetes, Cancer, High Blood Pressure any medical conditions, Medicare will cover you starting your first day of eligibility.

Medicare always starts the first of the month, usually the month of your 65^th birthday. There are ALWAYS exceptions with Medicare, but that is when most individuals become eligible. If your birthday is the 1^st of the month, your eligibility begins the 1^st of the month BEFORE your birthday.

If you are younger than 65 and are now eligible for Medicare for any reason, your medical coverage is the same. There are very few pre-existing condition limitations for Medicare coverage.

When starting Medicare, you will have all the same doctors and hospitals that you have seen, for all those conditions. You will just start with a new payer for those medical bills. The new payer will include Medicare Part A & B.

When you become eligible for Medicare Part A & B, you also must sign up for a Medicare Part D plan for prescription drug coverage. We will talk more about this soon, but know that if you delay joining Part D, there are rules that effect when you can join later.

Now back to Medicare Part A & B.

There are two exceptions to Medicare related to coverage of those pre-existing conditions: an open workman’s comp claim, and an open automobile insurance claim. When I say open, I mean these payers are still paying on the previous claim. Sometimes these types of claims are open for a lifetime, but sometimes they max out in payment and then close. Once these types of claims are closed, Medicare will need to be notified and then Medicare will pay as primary for any costs associated with those initial injuries.

There are a few situations where you might run into an initial denial but that’s because Medicare simply needs more information from the provider to pay the claim.

There are some limitations with other insurance products related to Medicare. If you stay in “original Medicare,” Parts A and B, then sign up for a Medicare Supplement or “Medigap” plan within 63 of Medicare eligibility, the Medicare Supplement Plan will also have no exclusions in coverage. If you stay with original Medicare and choose not to enroll in a supplemental plan or an alternative within 63 days, then most Medicare Supplement Insurance companies include a six-month pre-existing clause.

Here is a timeline: If you receive Medicare March 1, 2025 and enroll in a Medicare Supplement to begin by May 1, 2025, you will have no exclusions. If you begin Medicare March 1, 2025 and then don’t choose an additional Medicare Supplement Plan until July 1, 2025, you will have full Medicare coverage, but your Medicare Supplement may have a six-month pre-existing exclusion. I use the word “may” because some companies have a six-month pre-existing exclusion, some have two months. If you delayed getting additional insurance when you first started Medicare, you may want to look into those Medigap plans with a shorter pre-existing exclusion clause, as this could save you a significant amount of money.

If you become Medicare eligible and you decide to enroll in a Medicare Advantage Plan, there may be reasons you are not allowed to join. This is usually tied to the Medicare Part D benefit rules.

For Medicare Part D, you must enroll into an insurance coverage including Prescription Drug Coverage (either a stand-alone plan, or a Medicare Advantage Plan which includes Part D) at the same time you begin Medicare Part A & B. If you don’t do this when initially eligible for Medicare, you can only add a Part D plan during the Annual Open Enrollment Period (October 15 to December 7 each year). There are exceptions to this rule, but they apply to specific situations.

All of these rules are true for all individuals becoming eligible for Medicare. This includes those who are younger and getting Medicare due to a disability. Many people believe that some Medicare rules only apply to those 65 and older and that those who are eligible due to a disability have a different set of rules and that is not true. This is generally not true, and once you are eligible for Medicare for any reason, the enrollment rules are basically the same for everyone. There are always individual variables that impact you and your individual situation. So, looking for answers in advance of turning 65 is always a good idea.