Which Preexisting Conditions Are Not Covered by Medicare?

Fact Checked
Contributing expert: Travis Price, Medicare consultant
Published: March 15, 2022

Travis Price
Travis Price:
Medicare consultant
Travis Price:
Medicare consultant

Travis Price is a licensed independent health insurance agent specializing in Medicare private insurance programs, including Medicare Advantage and Part D drug plans. Price has been in the Medicare industry since 2004, first in South Carolina and now in the Traverse City, Michigan, area.

If you’re worried about Medicare covering preexisting conditions, don’t be. Original Medicare, Medicare Advantage Plans, and Medicare Part D plans cover preexisting conditions without exception. However, Medigap plans require a waiting period under some circumstances.

What Is a Preexisting Condition?

A preexisting condition is an established health condition you have before starting new insurance coverage, such as Medicare. Diabetes, cancer, liver, or kidney disease are just a few examples of preexisting conditions.

Does Medicare Cover Preexisting Conditions?

Medicare Parts A and B, also known as Original Medicare, do cover preexisting conditions. You will have the same costs and benefits that people without preexisting conditions would have coverage at the same rates.

Do Medicare Part D Prescription Drug Plans Cover Medications for Preexisting Conditions?

Medicare Part D drug plans cover medications for pre-existing conditions. As with Original Medicare, you will not pay a higher amount in premiums or benefits because of a preexisting condition.

Does Medicare Supplement Insurance Cover Preexisting Conditions?

Medicare Supplement Insurance Plans cover preexisting conditions. But unlike most other Medicare parts (Original Medicare or Part D), Medigap plans may have a six-month waiting period to cover your conditions.

Medicare requires Medicare supplement plans to waive this requirement if you’ve had creditable coverage, such as an employer or union health plan, for the last six months with no more than a 63-day gap prior to signing up for Medicare. You can also skip the waiting period if you have guaranteed issue rights.

Do Medicare Advantage Plans Cover Preexisting Conditions?

Yes. Medicare Advantage Plans cover preexisting conditions, as with Part A and B, without an increase in premium or a decrease in benefits provided.

Can You Be Denied Medicare Coverage Because of Preexisting Conditions?

Under Parts A, B, Medicare Advantage, and Part D, you can’t be denied coverage due to preexisting conditions.

Medicare supplements, however, can be a slightly different story. If you’re signing up for a Medigap plan during your Initial Enrollment Period (IEP), a Special Enrollment Period (SEP), or Guaranteed Issue period, the insurance company cannot deny your application for coverage.

However, you have the right to switch Medicare Supplement plans at any time of the year, provided that you can pass medical underwriting. Your preexisting condition could prevent you from switching Medicare Supplement plans outside of a qualified enrollment period. However, this largely depends on the condition and treatment you are receiving.

What Are Guaranteed Issue Rights?

Medicare Guaranteed Issue Rights require insurance companies to offer you a Medigap plan under certain circumstances. When you qualify for a Guaranteed Issue Right, all of your conditions must be covered and you can’t be charged more for your policy due to any health problems.

You have a Guaranteed Issue Right if you:

  • Have a Medicare Advantage Plan and your plan leaves Medicare, is no longer offered in your area, or you move outside of the service area for the plan
  • Have Original Medicare and health coverage that pays after Medicare, but the plan is ending
  • Have Original Medicare and a Medicare SELECT policy, but you’re moving out of the policy’s service area
  • Have a Medicare Advantage Plan or a PACE plan you signed up for during your IEP but are switching to Original Medicare within the first year of joining
  • Want to switch back to Medigap after you joined a Medicare Advantage Plan for the first time and have been in the plan less than a year
  • Lose your Medigap policy due to no fault of your own, such as the bankruptcy of the insurance company
  • Leave a Medigap policy or Medicare Advantage Plan because the insurance company misled you or hasn’t followed the rules

Do My Preexisting Conditions Qualify Me for a Medicare Special Needs Plans?

Certain pre-existing conditions qualify you for an Special Needs Plan (SNP) if there is one available in your area. You can enroll in these plans at any time, and they can provide additional services to help you manage your preexisting condition.

If your preexisting condition ceases to exist, you would have a SEP to switch to a regular Medicare Advantage Plan.

Below is a list of common conditions that have SNP plans associated with them:

  • Autoimmune disorders: Celiac disease, lupus, and rheumatoid arthritis
  • Cancer
  • Certain disabling behavioral health conditions
  • Chronic cardiovascular disease
  • Chronic drug dependence and/or alcoholism
  • Chronic heart failure
  • Chronic lung disorders: Asthma, chronic obstructive pulmonary disease (COPD), emphysema, and pulmonary hypertension
  • Dementia
  • Diabetes mellitus
  • End-stage liver disease
  • End-stage renal disease (ESRD) requiring dialysis
  • Hematological disorders: Deep vein thrombosis (DVT), sickle cell anemia, and thrombocytopenia
  • Neurological disorders: Epilepsy, multiple sclerosis, Parkinson’s disease, amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
  • Stroke

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