Do Medicare Advantage Plans Have Guaranteed-Issue Rights?
Last Updated : 09/15/20186 min read
If you’re interested in Medicare Advantage (Medicare Part C) but have pre-existing health conditions, you may be wondering whether your medical history may make it harder to find a plan – or whether you may have to pay more for coverage.
Medicare Advantage, or Part C, is another way to get your Medicare benefits. Instead of getting your Medicare Part A and Part B coverage through Original Medicare, your benefits are administered through a Medicare health plan, such as an HMO or PPO.
When people talk about “guaranteed-issue rights,” they’re usually referring to special protections you may have with Medicare Supplement (Medigap) plans. Medicare Supplement insurance is additional coverage you can get to help with out-of-pocket costs in Original Medicare. If you have guaranteed-issue protections, you have the right to enroll in any Medicare Supplement plan offered in your service area, regardless of health status or pre-existing conditions.
Even though the term “guaranteed-issue rights” usually refers to Medicare Supplement coverage, Medicare Advantage plans do cover most pre-existing conditions, with some exceptions (see below). Here’s an overview of guaranteed-issue rights, including the specific situations you may have them and whether you can enroll in a Medicare Advantage plan with guaranteed issue.
Please note that Medicare Advantage plans and Medicare Supplement insurance are two different types of health insurance, and they don’t work together.
What are guaranteed-issue rights?
As mentioned, guaranteed-issue rights are special rights you have to purchase Medicare Supplement insurance, regardless of pre-existing conditions or medical history. If you have these protections, any Medicare Supplement plan offered in your service area must sell you a plan even if you have health problems; the plan can’t charge you higher premiums due to health or require medical underwriting. Keep in mind that the plan may base premiums off of other factors besides health (such as your age).
You don’t always have guaranteed-issue rights; in fact, you only get them in specific situations. For example, you have guaranteed-issue rights during your Medicare Supplement Open Enrollment Period, which is the six-month period that starts automatically when you’re 65 and have Part B. After this period is over, you only get them in special circumstances, like if you move out of your plan’s service area or lose your coverage because your Medicare Supplement plan goes bankrupt or leaves Medicare.
Without these guaranteed-issue protections, the Medicare Supplement plan may require medical underwriting, charge you higher premiums if you have health issues, or deny you coverage entirely. Keep in mind that even with guaranteed-issue rights, the Medicare Supplement plan may sometimes require a waiting period of up to six months before covering out-of-pocket costs related to your pre-existing condition. Original Medicare will still cover any services or treatment you need related to your pre-existing condition, but the Medicare Supplement plan may not until the waiting period is over. The exception is if you had at least six months of uninterrupted creditable health coverage (such as through an employer group plan) before enrolling in your Medicare Supplement plan. Check out this article for more information on the pre-existing condition waiting period. The waiting period doesn’t apply if you have guaranteed issue or enroll during your Medicare Supplement Open Enrollment Period.
Please note that if you’re under 65 and have Medicare because of disability, you may not be able to get a Medicare Supplement plan in every state; check with your state’s insurance department for more information.
Can I get a Medicare Advantage plan with guaranteed issue?
As mentioned, guaranteed-issue rights usually refer to special Medicare Supplement protections. However, that doesn’t necessarily mean you can’t get a Medicare Advantage plan if you have health problems. Medicare Advantage plans are required to cover at least the same level of benefits as Original Medicare (except for hospice, which is still covered through Part A). In addition, Medicare Advantage plans must cover any pre-existing conditions you may have before enrolling in the plan, with the exception of end-stage renal disease (ESRD) or lateral sclerosis (Lou Gehrig’s disease). Unlike Medicare Supplement coverage, there is no waiting period before the plan covers your pre-existing conditions.
Can I get a Medicare Advantage plan if I have end-stage renal disease?
Although Medicare Advantage plans cover most pre-existing conditions, most plans don’t cover end-stage renal disease. If you have Medicare and ESRD, you may not be able to enroll in a Medicare Advantage plan unless the plan is a special type of Medicare Advantage known as a Special Needs Plan or your situation falls into one of these few exceptions.
Medicare Advantage Special Needs Plans offer benefits tailored for members of three groups: people who live in institutions (such as nursing homes); people with Medicare and Medicaid; and people with certain chronic health conditions. These plans may offer special coordination services, provider networks, wellness programs, or other benefits to help you manage your unique situation or health condition. If there’s one available in your service area, you may be able to enroll in a Chronic-Condition Special Needs Plan for people with end-stage renal disease. Since availability varies by plan, make sure to check for plan options in your specific zip code if you’re looking for a Special Needs Plan that targets ESRD beneficiaries.
Hopefully, you now have a better idea what your rights are under Medicare Advantage and how these plans cover pre-existing conditions you may have. Would you like help finding plan options that could work for you? That’s what I’m here for. You can get started right now by using the links below to set up a phone appointment with me or have me email you plan information. Or, to start browsing right away, just click on the Compare Plans button on this page to view coverage options in your area. You can even enter your prescriptions, if you like, and narrow your search to only show plans that cover your medications.
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