If you are approaching Medicare eligibility and have been diagnosed with a medical condition or disease that will be a factor in your healthcare needs, you may be concerned about the effect your pre-existing condition may have on your Medicare coverage. You are right to gather as much information as possible before you make any healthcare decisions. Your choices can determine your health and financial well-being now and in the future, and it is crucial that you make some of those decisions within the first six months of your Medicare Part B enrollment.

Medicare coverage is available to individuals age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant). A pre-existing condition may affect the healthcare choices you make regarding your Medicare coverage.

For instance, if you are planning to receive your Medicare benefits through Original Medicare, you may want to consider purchasing a Medicare Supplement Plan to help cover some of the additional costs of treating your condition. Original Medicare helps cover many of your healthcare costs, but there are gaps in the coverage that can be filled by a Medicare Supplement, or Medigap, policy. As long as you purchase this Medigap policy within six months of enrolling in Medicare Part B, you cannot be prevented from purchasing any Medigap policy sold in your state due to your pre-existing condition. A pre-existing condition is a health problem you have before the date a new insurance policy starts. In some cases, the Medigap insurance company can refuse to cover your out-of-pocket costs for these pre-existing health problems for up to 6 months. This is called a “pre-existing condition waiting period.” After 6 months, the Medigap policy will cover the pre-existing condition. Coverage for a pre-existing condition can only be excluded in a Medigap policy if the condition was treated or diagnosed within 6 months before the date the coverage starts under the Medigap policy. After this 6-month period, the Medigap policy will cover the condition that was excluded. Remember, for Medicare covered services, Original Medicare will still cover the condition, even if the Medigap policy won’t cover your out of pocket costs, but you’re responsible for the coinsurance or copayment.

Although Medigap policies are regulated by the Federal government, each policy may offer their benefits for a variety of different premiums and costs. It is important to research the policies available to you and find the one that best meets your needs. Along with Original Medicare and a Medicare Supplement Plan, you might also consider your need for prescription drug coverage. Medigap plans cannot offer prescription drug coverage, so if your pre-existing condition requires the use of medications, a stand-alone Prescription Drug Plan (PDP) may be important to you.

If you are considering getting your Medicare coverage through a Medicare Advantage Plan, you should keep in mind that you cannot be turned down for a plan due to a pre-existing condition. If you do not enroll with a Medicare Advantage Plan within six months of enrollment in Medicare Part B, you may enroll during the annual election period from Octobert 15 through December 7 each year. Many Medicare Advantage Plans include prescription drug coverage. It is important that you compare these plans to determine if the benefits offered will meet your specific needs. For instance, if you are thinking about joining a Medicare Advantage Plan and are on a transplant waiting list or believe you need a transplant, check with the plan before you join to make sure your doctors and hospitals are in the plan’s network. Also, check the plan’s coverage rules for prior authorization.

Please note: If you have End-Stage Renal Disease (ESRD), you usually can’t join a Medicare Advantage Plan, except under specific circumstances.

If your pre-existing condition requires specific medications, you will want to review the plans you are considering to make certain that your medications are included in your plan’s formulary. The formulary is the list of prescription drugs covered by that particular plan. Each plan may cover different medications at different costs, so you should compare them carefully.

With careful research and consideration, you should be able to find the Medicare coverage that will meet your needs, including those associated with your pre-existing condition.