Medigap Coverage of Pre-Existing Conditions

Victoria Burke by Victoria Burke | Licensed since 2011

This article was updated on: 09/16/2018

People often ask me when the best time is to enroll in a Medicare Supplement (Medigap) policy. My answer is always the same: If you want the most plans available to you and especially if you have health issues, you should join a plan when you’re first eligible, during your Medigap Open Enrollment Period. This is the period when you have guaranteed-issue rights, and Medigap insurers can’t deny you coverage, require medical underwriting, or charge you a higher premium if you have health problems. Your Medigap Open Enrollment Period starts automatically once you’re at least 65 and have Medicare Part B. Outside of this period, you’ll only have guaranteed-issue rights in some situations.

One thing to keep in mind is that even if you sign up when you have guaranteed-issue rights, the Medigap insurance company can make you wait up to six months before covering your pre-existing conditions. Pre-existing conditions are any health problems you had before the insurance policy started. This delay in coverage is known as the pre-existing condition waiting period.

If you have guaranteed-issue rights, federal law forbids the insurer from denying you coverage or making you wait for your Medigap coverage to start. However, many people are surprised to learn that there’s a waiting period before certain pre-existing conditions are covered, even if they sign up during their Medigap Open Enrollment Period.

By law, Medicare Supplement plans can only delay coverage for any health conditions that were diagnosed or treated within six months before the Medigap policy start-date. This is known as the look-back period, the amount of time a Medigap plan can “look back” and delay coverage for certain health conditions.

During this six-month waiting period, you’ll still be covered for any Medicare-covered services you get for these pre-existing conditions, under Original Medicare, Part A and Part B. However, your Medigap plan may not cover out-of-pocket costs like copayments and coinsurance if you’re getting treatment for an excluded condition. After the pre-existing condition waiting period is over, the Medigap plan will cover out-of-pocket costs for these health conditions.

What does this mean for you? If you’re joining a Medicare Supplement plan, and you’ve been recently diagnosed with health conditions in the past six months, find out if the Medigap plan requires a pre-existing condition waiting period. If it does, you may want to budget accordingly for copayments and coinsurance costs, knowing the plan may not cover cost sharing for up to six months. If you’re switching Medicare Supplement plans, and your new plan delays coverage for pre-existing conditions, you may want to schedule doctor appointments and treatment for those conditions before changing plans, if possible.

Do you have questions about how Medicare Supplement plans cover pre-existing conditions? I can help you figure out your Medigap options.

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