Does Medicare Cover Pre-Existing Conditions?

Original Medicare (Part A and Part B) 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.

A man in hospital gown smiles as he talks with his nurses

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 can cover chronic conditions

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.

Find a Medicare Advantage plan that covers your condition

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

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