Under 65 with Pre-existing Condition: What are your Medicare coverage options

Jory Cross by Jory Cross | Licensed since 2012
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This article was updated on: 07/06/2018

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What is pre-existing condition?

According to the U.S. Department of Health & Human Services, a pre-existing condition is a health problem you had before the date that your new health coverage starts. Many conditions might be considered a pre-existing condition, such as cancer, diabetes, epilepsy, severe obesity, kidney disease, and many more according to the Kaiser Family Foundation. Under a law enacted on January 1, 2014, private health insurance companies can’t refuse to cover you or charge you more because you have pre-existing condition. This law may change according to pending legislation. A pre-existing should also generally not prevent you from getting Medicare coverage.

Can I enroll in Medicare with a pre-existing condition?

If you are 65 or older you may be automatically enrolled in Medicare regardless of your health status or pre-existing conditions. If you are under 65, a pre-existing condition may also be considered a disability and could in fact qualify you for Medicare.

The first step to getting Medicare under 65 is to apply for Social Security disability benefits. You can do this online. Social Security will consider many things in your application, including past work experience, severity of medical conditions, age, education, and work skills. To evaluate a disability, Social Security has a list of impairments in 14 different categories for adults age 18 and older. The list if impairments includes:

  • Musculoskeletal system
  • Special senses and speech
  • Respiratory disorders
  • Cardiovascular system
  • Digestive system
  • Genitourinary disorders (such as chronic kidney disease)
  • Hematological disorders (such as anemias)
  • Skin disorders
  • Endocrine disorders
  • Congenital disorders that affect multiple body systems
  • Neurological disorders
  • Mental disorders
  • Cancer
  • Immune system disorders

If you’re receiving disability benefits from Social Security for a disability or a pre-existing condition you may qualify for Medicare after 24 months. A Medicare card may be mailed to you about 3 months before your 25th month of disability.

Can I get Medicare Supplement with a pre-existing condition?

A Medicare Supplement plan sold by a private insurance company may help you pay for Medicare’s out-of-pocket costs, such as coinsurance, copayments, and deductibles. If you are over 65, a pre-existing condition should not prohibit you from enrolling in a Medicare Supplement plan as long as you enroll during the Medicare Supplement Open Enrollment Period. However, federal law does not require private insurance companies to sell Medicare Supplement plans to Medicare beneficiaries under 65. That means that you’re 42 years old and have qualified for Medicare through a liver condition, you may not be able to buy a Medicare Supplement plan to help you pay Medicare coinsurance, copayments, or deductibles. However, some states do require private insurance companies to sell Medicare Supplement plans to Medicare beneficiaries under 65. These plans may cost you more than they would cost someone over 65.

Can I get Medicare Advantage with a pre-exiting condition?

Medicare Advantage (also called Part C) is another way to get your Part A and Part B benefits from a private insurance company approved by Medicare. By law, Medicare Advantage plans must cover everything that Medicare Part A and Part B cover, except hospice care, which Part A still covers. Medicare Advantage plans often have additional benefits that Medicare Part A and Part B don’t generally cover, such as routine vision coverage, routine dental coverage, or prescription drug coverage. Another benefit of a Medicare Advantage plan is that it may set an out-of-pocket maximum, unlike Medicare Part A and Part B which have no out-pocket maximum. You can generally get a Medicare Advantage plan even if you have a pre-existing condition. The requirements to enroll in a Medicare Advantage plan are:

  • You live in service area of the plan you want to join (not all plans are available in all areas).
  • You have Medicare Part A and Part B.
  • You don’t have end-stage disease (ESRD).

If your pre-existing condition is ESRD, you may not be able to get a Medicare Advantage plan, but in some cases you might be able to get Medicare Advantage with ESRD. Other pre-existing conditions, such as schizophrenia, cancer, amputation, or diabetes will generally not prohibit you from getting a Medicare Advantage plan if you qualify for Medicare.

Can I get Medicare Part D with a pre-existing condition?

Medicare Part D is for prescription drug coverage. Prescription drugs are usually not covered by Medicare Part A and Part B except in limited circumstances. You can usually get Medicare Part D coverage if you are under 65 and have a pre-existing condition, but you will typically have a waiting period similar to your waiting period to get Medicare coverage. You can sign up for Medicare Part D during a 7 month period. This period includes the three months before your 25th month of getting Social Security benefits, your 25th month of getting disability benefits, and 3 months after your 25th month of getting disability benefits. Keep in mind this enrollment period is tied to the time you started getting disability benefits, not the time your pre-existing condition began or was diagnosed.

Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.

The product and service descriptions, if any, provided on these Medicare.com Web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

 

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