Medicare Coverage and Pre-existing Health Conditions

Original Medicare

The good news is that everyone enrolling in Medicare has all pre-existing conditions covered, with no limitations or health questions to answer. You may enroll in Medicare by aging in at 65 or by qualifying for Medicare after 24 months of Social Security disability income benefits.

Your inpatient needs will be covered by Part A, and outpatient needs will be covered by Part B, regardless of pre-existing conditions. Additionally, you may enroll in a Part D prescription drug plan to cover needed medications.

During your initial open enrollment window (the 7 months surrounding your eligibility), you may also enroll in a Medigap plan without health limitations or exclusions.

Medicare Supplement (Medigap) Plans

In the case of supplemental plans, when you enroll makes all the difference. You can enroll in a Medigap policy, and have pre-existing conditions covered if you enroll during your one-time open enrollment period or under some circumstances that trigger guaranteed issue rules. By federal law, Medicare will not ask you any health questions when you enroll; but Medicare supplement companies can choose to limit your benefits or decline you if you miss your one-time open enrollment period when you first get Medicare.

If you can analyze your situation and enroll in the right plan from the start, It may save a great deal of money and angst in the long run.

Medicare Advantage Plans

There is another option; a Medicare Advantage plan, which fits some people better. Medicare Advantage plans will accept members without regard to pre-existing conditions. It is, however, important to consider your options carefully. Simply signing up for the cheapest plan, without considering your unique needs can lead to greater expenses in later years.

Two Medicare Plan Options; Two Ways to Pay

When you are first eligible to enroll in Medicare, you have a choice between two types of coverage; Original Medicare and a supplemental policy (Medigap) or Medicare Advantage. Medicare supplements have higher premiums upfront, with little or no back-end expenses. Medicare Advantage plans have much lower premiums upfront; often zero premium, but more back-end expenses.

This is an important choice; more so if you have a chronic condition that requires frequent medical care. If you do not anticipate high usage, Medicare Advantage can save you money. But, as with most things, there are trade-offs to consider. Remember that switching plans later, from Medicare Advantage to Medigap may involve undergoing medical underwriting, and you may find it difficult; even impossible; to enroll in a Medigap plan.

Medicare Advantage members generally are limited to seeing providers in the plan’s network. That may be difficult in less populated areas, with fewer choices.  Also, there are copays for healthcare services that can really add up. While some services, such as seeing your primary care provider, may not incur a copay, other services may involve a copay of 20% of the cost of the services.

For example, if you generally see a specialist, such as a cardiologist or an endocrinologist twice a month for  monitoring of your condition, you will incur two specialist copays per month.

If your plan charges $45 for a specialist visit, that means spending at least $90 for those two visits. Then, there may be additional copays for diagnostic lab tests, imaging, and/or surgeries. Your pre-existing conditions will cause some spending that you can be anticipated.

The other way, enrolling in a Medigap plan, like  Plan G may be more costly to enroll in; for example, $125/month. But the coverage is comprehensive. Other than your Medicare Part B deductible, there may be no other costs. Specialist visits, lab testing, imaging, and surgeries require no co-pays. Additionally, if you have a chronic condition like diabetes, testing supplies may be covered 100% from approved medical equipment suppliers.

All things considered, this may be the most cost-effective choice.


The best way to receive Medicare benefits depends on several factors. It is a good idea to discuss your options with a licensed agent who represents several companies, as each company has its own underwriting guidelines.

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