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Medicare and Pre-Existing Conditions

A pre-existing medical condition refers to any health condition or illness that was present prior to the effectivity of an insurance policy. There are no general pre-defined sets of pre-existing medical conditions. These pre-existing conditions can vary according to the health insurance provider.

The range of pre-existing medical conditions can include asthma, heart ailments, or cancer.

Insurance companies usually define pre-existing conditions under its “objective standard” and “prudent person” definition. The objective standard defines pre-existing medical conditions as those that a person has already received treatment for or was earlier diagnosed with prior to enrollment in the health insurance policy.

The prudent person definition on the other hand states that a pre-existing condition is a medical condition whose symptoms were exhibited prior to enrollment. A person who showed symptoms of cancer for example, should have seen a doctor for diagnosis of the medical condition. The prudent person definition goes into effect if the person showed symptoms of the disease but did not have these checked by a medical professional.

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Medicare Supplement (Medigap) and Pre-existing Conditions

Medigap plans are offered by private insurance companies to fill the gaps in original Medicare coverage. These plans can be used to pay for out-of-pocket costs such as deductible, coinsurance, and copayments under original Medicare.

Private health insurance companies use pre-existing medical condition as a basis for denying a health insurance application or adjust charges (premiums) accordingly.

People planning to enroll in a Medicare supplement plan must do this within the Medigap Open Enrollment Period to be guaranteed acceptance to any Medicare supplement plan. It is the six-month period that begins when a person turns 65 and enrolled in Medicare Part B. During this period, a private insurance provider cannot deny or charge Medigap applicants a higher premium due to health conditions.

A waiting period is required for those who enroll in a Medigap plan after the Medigap Open Enrollment Period.  Applicants must wait even after the application for Medigap has been accepted. This is also referred to as the “pre-existing waiting period” or “look back period.” Pre-existing conditions include those that the applicant was diagnosed with or treated within six months of the insurance policy’s start date.

Original Medicare (Part A and Part B) covers pre-existing conditions. However, a beneficiary must apply for Medicare supplement insurance within initial six-month open enrollment period to take full advantage of these benefits. During this period, no medical insurance plan including Medigap or Medicare Supplement insurance can deny coverage. Applications made to a Medicare supplement insurance policy made after the open enrollment period can be denied for health reasons.

How much does Medicare cover?

Original Medicare provides coverage for pre-existing conditions through Part A (hospital insurance) and Part B (medical insurance). Just like any typical coverage, beneficiaries must make certain payments including deductibles, coinsurance, and copayments.

Medicare Part A covers:

  • Hospitalization
  • Skilled nursing facilities
  • Home health care
  • Hospice care

Medicare Part B includes coverage for:

  • Emergency room visits
  • Ambulance services
  • Durable medical equipment
  • Lab work
  • Doctor office visits
  • Orthotics and prosthetics

Medical treatments and services are covered under Original Medicare (Part A and Part B). Eligible beneficiaries are entitled to coverage for medical services regardless if these are for pre-existing medical conditions.


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