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Does Medicare Cover Pre-Existing Conditions?

Dec 9, 2021

You’re approaching your 65th birthday, ready to settle into retirement, and getting ready to sign up for Medicare. Unfortunately, you developed a chronic illness along the way, and you’re not sure whether Medicare will cover your pre-existing condition. You’re asking yourself: will I be able to sign up for Medicare? Is my specific chronic condition included? If so, will the premiums be too expensive for my limited budget? These are important questions of concern as nearly 50% of Americans develop chronic medical conditions before they reach retirement age and are able to sign up for Medicare. Let’s discover the answers together.

Medicare Covers Pre-existing Conditions

The bottom line is: Yes! Medicare covers preexisting conditions. Under provisions of the Affordable Care Act, Medicare provides coverage for any medical expenses related to preexisting conditions developed prior to your Initial Enrollment Period. This extends to all main provisions of Medicare including:

  • Part A which provides hospital insurance and covers all medical needs during hospital stays
  • Part B which provides medical insurance and covers all medical needs related to doctor visits
  • Part D which offers prescription drug insurance and covers the medicines needed to treat your health conditions, including preexisting conditions. 

Which Pre-Existing Conditions are Covered?

All of them. All preexisting medical conditions are covered under Medicare Part A, Part B, and Part D. That includes diabetes, ALS, cancer, epilepsy, asthma, an autoimmune disease, or all other chronic illnesses and preexisting conditions. Even if you have been diagnosed with End-Stage Renal Disease (ESRD), you will qualify for Medicare. (However, if have ESRD, you don’t have to wait until you’re 65 to enroll in Medicare). 

Will I Pay Extra for the Coverage?

No. Due to changes made through the Affordable Care Act, there will be no additional cost for Medicare coverage if you have preexisting conditions. Premiums for Part A will be in the same general range (for instance, between $0 to $468 in 2020) and the standard premium for Part B ($144 in 2020) will remain the same regardless of your health conditions. Most people will qualify for the $0 premium for Part A, while most beneficiaries pay the standard Part B premium.  

Are There Any Exceptions?

Preexisting conditions are automatically covered under Medicare Part A for hospital stays, Part B for doctor’s visits, and Part D for related prescription drugs. Yet, there may be some coverage and cost variations related to coverage from private insurance providers related to Medigap and Medicare Advantage Plans. 

Medicare Supplement 

There are some medical expenses that are not covered through Medicare Part A or Medicare Part B. Medicare Supplement, also known as Medigap insurance, are policies sold by private insurance companies that help cover some of the remaining balance. Medigap plans have more limitations related to preexisting conditions.

Notably, you won’t be denied coverage and you won’t pay any extra if you sign up for Medicare Supplement during the Open Enrollment Period. The Medicare Supplement Open Enrollment Period is a six-month window that begins the month of your 65th birthday. If you don’t sign up during the open enrollment period and decide to do so later, you could be charged more for the same benefits, and may even be denied depending on your preexisting condition.

Medicare Advantage

Medicare Advantage (MA) plans are insurance programs offered by private insurance companies. They contract with Medicare to offer the same benefits as Medicare Part A and Part B, and most also include prescription drug plans through Medicare Part D. 

Like Medicare Part A and Part B, you can’t be charged more for preexisting conditions if you sign up for a Medicare Advantage plan. However, because MA plans are offered by private insurance companies, basic costs will vary by plan. Even so, you can’t be denied coverage based on preexisting conditions, except in a few cases like end-stage renal disease (ESRD). 

If you find this all a little bit overwhelming and would like more assistance regarding what is and is not covered under Medicare. You can get more detailed information by speaking to a licensed and qualified Medicare insurance specialist.

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