Does Medicaid Cover Preexisting Conditions?

In this article...
  • Find out about when Medicare and Medicaid are likely to cover preexisting conditions so that you can better anticipate the cost of care and treatment.

Preexisting conditions are common among older adults. The U.S. Department of Health and Human Services reports that 84% of adults aged 55 to 64 have one or more preexisting conditions and that rates are even higher among those 65 and older. If you're one of the millions who have a health condition, you may worry about your eligibility for government health care programs. The good news is that Medicaid and Medicare generally cover preexisting conditions.

Does Medicaid Cover Preexisting Conditions?

A preexisting condition is a health problem that you already have before a health plan takes effect. Historically, private insurers would often deny people with preexisting conditions health insurance coverage or charge them higher rates than their peers. The Affordable Care Act (ACA) passed in 2010 prohibits insurance companies from continuing this practice.

Even before the changes to insurance coverage due to the Affordable Care Act, people with preexisting conditions were eligible for Medicaid coverage. From its formation in 1965, Medicaid has treated individuals who have health conditions the same as those without preexisting conditions. Medicaid won't decline to pay for a covered service even if it's related to a preexisting condition, and you won't be charged more for copays and coinsurance because of a condition that you had before you signed up for Medicaid.

Because Medicaid offers care for everyone, the program provided a way for people who couldn't qualify for health insurance to get coverage prior to the passage of the ACA. Examples include pregnant women, individuals with functional disabilities and people with HIV. The expansion of Medicaid created by the ACA gave 15 million adults access to health care through their states' programs regardless of preexisting conditions.

What Preexisting Conditions Are Not Covered by Medicare?

Much like Medicaid, Medicare plans generally cover preexisting conditions. Original Medicare (Parts A and B) have always accepted people with preexisting conditions. Initially, Medicare Advantage or Medicare Part C plans could decline coverage for people suffering from end-stage renal failure. As of 2021, this practice is no longer allowed.

Do Medigap Plans Cover Preexisting Conditions?

Medicare Supplement or Medigap plans treat preexisting conditions differently than Original Medicare and Medicare Advantage Plans. These plans help cover some of the portion of health care costs that you're responsible for paying out of pocket under Original Medicare.

Under current rules, a Medigap plan can't deny you coverage for a preexisting condition or make you wait for your coverage to take effect. However, Medicare supplement plans are permitted to make you wait for coverage for expenses related to a preexisting condition for a set period called the exclusionary period. Other health care costs will still be paid during that time.

For example, if you have diabetes and you visit your doctor to evaluate your treatment plan, Medicare Part B will usually cover 80% of the cost of the visit, and you'd pay the remaining 20%. During the exclusionary period, your Medigap plan won't help you pay. After the exclusionary period ends, the plan may provide payment for all or some of the 20% that you owe.

If you have diabetes and visit the doctor for a sprained ankle, you'd be responsible for 20% of the cost of the visit, but Medigap would likely help cover the cost even during the exclusionary period because the injury has nothing to do with your preexisting condition.

Medicare Supplement plans develop their own guidelines regarding which preexisting conditions are subject to an exclusionary period.

How Long Can Preexisting Conditions Be Excluded?

Medigap plans may exclude preexisting conditions from coverage for the first 6 months of your policy. After that, your plan must cover any expenses that it would ordinarily cover for people without preexisting conditions.

Keep in mind that Medicare Supplement plans don't pay for everything, even for those without any health conditions. Each plan has its own coverage guidelines, which you can obtain from the insurance provider.

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