Will a pre-existing condition affect Medicare eligibility?

A fellow caregiver asked...

My wife has my pre-65 medical insurance now but will be turning 65 in March. She was just informed that she will have to have heart surgery for a bad valve that she has had for many years. What should I do for her insurance? Does the fact that she had this problem for a long time prevent her from getting any insurance other then Medicare plans A and B?

Expert Answer

You're doing the smart thing by planning ahead. Medicare leaves considerable gaps in coverage that you'd have to pay out of pocket if you don't have some kind of supplemental insurance coverage. There are two kinds of insurance your wife could buy to supplement Medicare Part A (hospital insurance) and Medicare Part B (medical insurance, including doctors and other outpatient care). And she can buy either type of coverage -- despite her pre-existing condition -- as long as she does so within six months of first enrolling in Medicare.

One type of supplemental coverage is known as [Medigap] (https://www.caring.com/articles/medigap-insurance) insurance. This is a private health insurance policy, regulated by the federal government, specifically designed to fill in the gaps of Medicare coverage. There are a dozen types of Medigap policies , each providing slightly different coverage. These Medigap policies are offered by private insurance companies, each one having to provide the minimum coverage mandated by the federal government for that type of policy, but some also offering some small extra coverage. The government does not get involved in what the insurance companies can charge for these policies, so premiums differ widely from policy type to policy type, and from company to company. Your wife can enroll in any Medigap policy sold in your state, despite her heart condition, if she does so within the first six months after enrolling in Medicare Part B.

Another option your wife will have is to enroll in a Medicare Part C Medicare Advantage plan, sold by private insurance and managed care companies. A Medicare Part C plan would be instead of a Medigap plan. With a Medicare Part C plan, your wife would actually leave the Medicare Part A and Part B programs, but she would get all of the coverage offered by Medicare Part A and Part B, plus extra coverage offered by the Medicare Part C plan. This extra coverage would fill in the gaps in what Medicare Part A and Part B pay, just as a Medigap policy would do. Many of these Medicare Part C plans are managed care plans (such as an HMO), and may not provide as great a choice of doctors and other providers as original Medicare plus a Medigap policy, but the Medicare Part C plans tend to be slightly cheaper than original Medicare plus a Medigap plan. Your wife is guaranteed the right to enroll in any Medicare Part C plan open to new enrollees in your state, regardless of her pre-existing conddition, as long as she applies within six months of first enrolling in Medicare Part A and Part B.

A final word of caution: Medicare Part A and Part B do not cover most outpatient prescription drugs. To get her prescription drugs covered (which she'll probably need after heart surgery), your wife will also have to buy a separate Medicare Part D prescription drug policy, or enroll in a Medicare Part C Medicare Advantage plan that includes prescription drug coverage.