One of the biggest worries people have about switching to Medicare is receiving coverage while having a current health problem or pre-existing condition. Many are concerned about whether they will be able to purchase Medicare Supplement insurance – often referred to as Medigap – or whether they will be denied coverage or left with extremely expensive premiums because of a pre-existing condition. The good news is you have options and rights.
In most cases, you can receive Medigap coverage even if you have a pre-existing condition. There are full federal guarantees and protections – commonly known as guaranteed-issue rights- that ensure that you will receive coverage. However, these rights are only relevant in certain timeframes and situations. Keep reading to learn about your Medicare Supplement and Medigap rights and what steps you can take to ensure your coverage.
WHAT IS MEDICARE SUPPLEMENT/MEDIGAP INSURANCE?:
Medicare Supplement insurance – commonly referred to as Medigap- is private health insurance that helps supplement Original Medicare. It helps provide additional coverage than what is included with Original Medicare. There are several plans available, and they differ in the level and areas of coverage. Premiums vary by state and by carrier. Because of the wide variety of plans, it’s easy to find the perfect Medicare Supplement insurance that meets your coverage requirements while also fitting in with your budget.
WHEN IS THE BEST TIME TO ENROLL?
To qualify for Medigap coverage with a pre-existing condition, it is important that you apply during your Medigap Open Enrollment Period.
Your Medigap Open Enrollment Period automatically starts on the first day of the month you’re at least 65 years old and enrolled in Medicare Part B. The period lasts six months.
During this timeframe, you have guaranteed-issue rights. This means that Medigap insurers are not allowed to make decisions based on your pre-existing conditions. Legally, they can’t deny you coverage, require medical underwriting, or charge you a higher premium if you have a history of health problems.
This is why it is critical to apply for Medicare Supplement insurance during your Medigap Open Enrollment Period. When Open Enrollment is over, you’ll only have guaranteed-issue rights in a few specific situations.
IS THERE A PRE-EXISTING CONDITIONS WAITING PERIOD?
Although insurers are not allowed to deny you coverage during Open Enrollment, there is still a waiting period that occurs before certain pre-existing conditions are covered. This waiting period can last up to six months.
During the waiting period, you will receive coverage for your pre-existing conditions under Original Medicare (Part A and Part B). However, Original Medicare alone may not cover co-payments and other out-of-pocket costs associated with your pre-existing condition. Once the pre-existing condition waiting period is over, the Medigap coverage will take effect and help cover the remaining costs.
Keep this pre-existing waiting period in mind when creating your budget. Find out if the Medigap coverage you’re interested in requires a pre-existing condition waiting period, and if it does, make sure to factor in the costs of copayments and out-of-pocket expenses that you may incur during this time frame.
WHAT IF I MISSED OPEN ENROLLMENT? DO I STILL HAVE ANY RIGHTS?
If you did not sign up for Medicare Supplement insurance during your Medigap Open Enrollment Period, you may still be able to benefit from additional guaranteed issue rights.
You will qualify for guaranteed issue rights if you lose coverage or have changes in your health-care that are out of your control. If this were to occur, insurance companies cannot take your pre-existing condition into account and must sell you Medigap coverage. You will not be charged more because of your health problems or pre-existing condition. However, guaranteed issue rights are very specific and apply to only a few select circumstances. That’s why it’s highly recommended to sign up for Medicare Supplement plans during the Medigap Open Enrollment Period.
There are also guaranteed issue trial rights which give you the ability to switch over to Medigap coverage after buying a Medicare Advantage plan. However, for these rights to be taken into account, you have to decide to switch to a Medicare Supplement plan within the first year of purchasing Medicare Advantage. If you decide to switch to Medigap coverage within the year window, insurance companies cannot deny you coverage or raise your rates due to a pre-existing condition.
WHAT IF I DON’T QUALIFY FOR GUARANTEED ISSUE RIGHTS?
If you missed Medigap Open Enrollment and you do not qualify for any of the guaranteed-issue rights situations outlined above, your coverage is up to the subjectivity of the insurance company. Insurers often use medical underwriting to decide whether to grant coverage. Your age, gender, and pre-existing medical conditions you’ve been treated for during the previous six months will all be taken into consideration. Medical underwriting can also determine how much you have to pay in monthly premiums and whether your plan will have any coverage restrictions.
Remember, insurers are not allowed to use medical underwriting during your Medigap Open Enrollment Period.
WHAT IF I NEED TO CHANGE PLANS?
Switching from one Medigap coverage plan to another shouldn’t be an issue in regards to your pre-existing condition. It’s recommended that you switch plans during the Open Enrollment Period. During this time frame, Medicare Supplement plans cannot deny coverage or charge you higher premiums due to a pre-existing condition. If you are switching Medigap coverage plans, there should not be a waiting period unless you are seeking coverage for a new health issue that wasn’t covered previously.
It’s important to keep your current coverage until your new plan takes place to avoid any gaps in coverage.
Pre-existing conditions can be problematic when dealing with insurance. But that doesn’t mean you do not have options. Luckily, if you apply during the Medigap Open Enrollment Period, you should still receive coverage through your Medicare Supplement plan (after you have satisfied any required waiting periods for pre-existing conditions).
During this time frame, companies cannot deny you coverage or charge outrageous premiums. However, if you wait until after the Open Enrollment Period, insurance companies may have the ability to complete medical underwriting, a process that could result in higher premiums based on a pre-existing condition.
If you have a pre-existing condition, we recommend purchasing Medicare Supplement insurance as soon as you are eligible to help you get the best coverage possible. Check out these Medicare Supplement Plans for more information.