Does Medicare Cover Pre-Existing Conditions?

Yes, Medicare typically covers pre-existing conditions in most cases. However, you could be denied a Medicare Advantage policy (Medicare Part C) if you have end-stage renal disease (ESRD).

Medicare Advantage plans are sold by private insurers and combine Original Medicare (Medicare Part A and Part B) benefits into one single plan.

Every Medicare Advantage plan must provide the same hospital and medical benefits as Original Medicare, and Medicare Advantage plans cover most pre-existing conditions other than ESRD.

Man outside in nature

End-Stage Renal Disease and Medicare Advantage

Although Medicare Advantage is not typically available to those with ESRD, there are a few exceptions. You may be eligible for a Medicare Advantage plan with ESRD if:

  • You developed ESRD while you were already enrolled in a Medicare Advantage plan
  • You had a successful kidney transplant to treat your ESRD and are eligible for Medicare coverage
  • You enroll in a Medicare Special Needs Plan

Medicare Special Needs Plans

A Medicare Special Needs Plan (SNP) is a type of Medicare Advantage plan that is limited to people with specific diseases or conditions.

You may be eligible for a Medicare SNP if you have one or more of the following pre-existing conditions:

  • Chronic alcoholism
  • HIV/AIDS
  • Cancer
  • Drug addiction
  • Autoimmune disorder
  • ESRD requiring kidney dialysis
  • Diabetes
  • Chronic heart failure
  • Chronic lung disorder
  • End-stage liver disease
  • Disorder of the cardiovascular system

Important: All Medicare SNPs must provide Medicare prescription drug coverage, and most require you to stay within your SNP network for care.

Some Medicare SNPs may offer coverage for additional benefits such as hearing, vision and dental care.

Beneficiaries with chronic conditions have better outcomes with Medicare Advantage plans

A 2018 study found that people who have chronic health conditions experienced 23 percent fewer inpatient hospital stays as a member of a Medicare Advantage plan, compared to Original Medicare beneficiaries.

Medicare Advantage plan beneficiaries also experienced close to 33 percent fewer emergency room visits that beneficiaries of Original Medicare.

For someone with a pre-existing condition, enrolling in a Medicare Advantage plan could potentially lead to better health outcomes than sticking with Original Medicare.

Enroll in a Medicare Advantage plan

If you qualify for Medicare and have a pre-existing condition, speak with a licensed insurance agent to learn more about your options.

Call TTY Users: 711 24 hours a day, 7 days a week to speak with an agent who can help you compare plans in your area and find the right fit for your needs.

Copyright © 2018 TZ Insurance Solutions LLC. All rights reserved.

MedicareAdvantage.com is a website owned and operated by TZ Insurance Solutions LLC. TZ Insurance Solutions LLC and TruBridge, Inc. represent Medicare Advantage Organizations and Prescription Drug Plans having Medicare contracts; enrollment in any plan depends upon contract renewal.

Plan availability varies by region and state. For a complete list of available plans, please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

Medicare has neither reviewed nor endorsed this information.