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Pre-Existing Conditions on Medicare

Published by Mike Lovell on

Pre-Existing Conditions

A pre-existing condition is a medical condition that started before a person’s health benefits went into effect.  If you are on Medicare, you are probably concerned about pre-existing conditions.  Because you have probably had some form of health treatment before.  Maybe you even have some ongoing issues that you are seeing a doctor for right now.

It’s important to understand how starting Medicare will impact coverage for your ongoing medical issues.

Depending on how you decide to get your Medicare coverage, you will have different rules regarding your medical issues.  So here are some of the Medicare coverage options so you can see how you will be impacted by pre-existing conditions.

Original Medicare

Have you ever had any medical issues?  Things like cancer or diabetes.  Or maybe you are getting treatment right now for something else that requires physical therapy?  Obviously you are concerned if Medicare is going to cover you when you get started on Medicare.

I have good news.

Because anything Medicare covers will be covered starting on the effective date on your Medicare card.    It does not matter if you have had prior coverage or not.  It also does not matter if you have a current health condition you are getting treatment for right now.

You will be covered by Original Medicare with no limits or exclusions based on pre-existing conditions.  So you don’t need to be concerned about pre-existing conditions and Medicare not covering you.

Medicare Supplements

Medicare supplements fill in the gaps of Original Medicare.  And they are sold by insurance companies so they may have some rules that are slightly different from each other.  But the state of Wisconsin has a rule regarding pre-existing conditions for Medicare supplements.

Pre-existing conditions are only a factor if you start your Medicare supplement coverage immediately after you have a gap in coverage.

So if you have health insurance right now and are starting Medicare, plus your Medicare supplement then you will have coverage immediately.  With no concerns or limitations about pre-existing conditions.

But, if you do not have health insurance right now then rules could be different for you.  If you are about to start Original Medicare plus a Medicare supplement and you don’t have health insurance then you could be impacted by how pre-existing conditions are covered.

Medicare will cover you for everything Medicare covers day 1 of your effective date.  But your Medicare supplement coverage can deny claims for your pre-existing conditions for up to 6 months.  This 6 month time frame only applies to conditions that can be considered pre-existing.

So that means if you break your leg before your Medicare coverage starts and you have no health insurance then your Medicare supplement company could deny claims for follow up treatment for your leg for the first 6 months of your policy.   But they could not deny claims if you have a heart attack after your Medicare supplement policy started.  That would be covered because it is not a pre-existing conditions.

And after 6 months, all Medicare supplement companies in Wisconsin are required to cover all pre-existing conditions.

Prior Insurance – Changing from one Medicare supplement to another

You may need to be approved when changing to a new Medicare supplement company.  But once you are approved then your new supplement company is required to cover your pre-existing conditions immediately with no limits or restrictions.

Medicare Advantage

Medicare Advantage is Medicare coverage from an insurance company.  So you get your Medicare benefits from an insurance company instead of Original Medicare.  This can sound complicated but how pre-existing conditions are covered is easy.

Medicare Advantage provides coverage for all conditions starting on your effective date.  There is no review for pre-existing conditions so you don’t have waiting periods for things to be covered.

Prescription Drug Plans

Prescription drug plans have coverage that starts on your effective date.  Similar to Medicare Advantage plans, there is no review of prior coverage.  Which means no concerns about pre-existing conditions.

RECAP

The following 3 coverage options do not look at prior coverage.  So there are no concerns for pre-existing conditions:

  • Original Medicare
  • Medicare Advantage
  • Prescription Drug Plans

The following coverage option can have potential issues with pre-existing conditions:

  • Medicare supplements

If you have health insurance before starting your Medicare supplement then you will not have a pre-existing clause.  Which means your Medicare supplement will cover you from day 1.  This includes changing from one Medicare supplement company to another.

But if you don’t have health insurance then your Medicare supplement company can deny claims for pre-existing conditions in Wisconsin for up to 6 months.

Have other questions on Medicare?  Or wondering which Medicare supplement companies will cover pre-existing conditions sooner than 6 months? Contact me and I can help you sort through your options.

Mike Lovell

608-571-4461

Mike@askMedicareMike.com