Medicare Advantage Plan and Pre-Existing Conditions


Medicare Advantage plans cannot reject to sell the plans to customers who apply for the same during Open Enrollment Period (OEP). They have to sell the policies to the customers during OEP even if they have pre-existing health conditions. The insurance companies cannot delay the start of coverage if the application has been made during OEP or if the customers have guaranteed-issue rights. They can, however, include a waiting period which is generally for 6-months. This means that the customers will not be able to take the benefits of the Medigap policy if they are diagnosed or treated for any pre-existing conditions up to 6-months from the start of coverage. The salient details pertaining to pre-existing conditions and Medigap policies are provided below:


Impact of the Waiting Period

Waiting period means that the customers will not be able to avail the benefits of the Medicare Advantage plan and they need to pay their own out-of-pocket expenses related to coinsurance, copayments, deductibles etc. till the waiting period is in effect. They need to plan their budget considering that the Medigap policy will not meet the expenses on pre-existing condition for 6-months from the start of coverage of the policy. The customers also need to consider the impact of switching Medigap policies and pre-existing conditions. If the new plan delays the coverage for pre-existing conditions, then they should plan their doctor appointments and treatment of the pre-existing conditions before switching the plans.


Reducing the Waiting Period

The customers can generally not completely eliminate the waiting period under the Medicare Advantage plans. However, they can reduce the waiting period if they had at least 6-months of creditable coverage before applying for the Medicare Advantage plan. The creditable health coverage includes individual health insurance, group health insurance (from the employer), TRICARE etc.  In addition, there should be no break in the creditable health coverage for more than 63 days. Generally, the Medigap’s pre-existing waiting period is reduced by the number of months of the creditable health coverage held by the customer before enrolling into the Medigap for up to 6-months.


Switching Plans and Pre-Existing Conditions

The customers need to plan for their pre-existing conditions carefully before switching the Medicare Advantage plans. They should keep their existing coverage till the insurance company confirms the start of coverage of their new plan. The new plan can also impose a waiting period for pre-existing conditions. Under such situation, the customers should schedule their treatment and the related healthcare appointments related to the pre-existing conditions before switching plans. This will ensure that their existing plan meets the out-of-pocket expenses and they are not burdened by the same.