Question: I am turning 65, retired, and will be getting Medicare soon. I am confused about how Medicare handles the coverage of my already existing medical problems. There is so much talk about pre-existing conditions and coverage rules. Does Medicare cover these pre-existing medical conditions, or do I have to wait a while before they are covered?

Answer: Congratulations on reaching Medicare eligibility! Your health care coverage has become very comprehensive insurance. When you become Medicare eligible, Medicare covers all your pre-existing medical conditions. If you have Diabetes, Cancer, High Blood Pressure or any medical condition, Medicare will cover you starting your first day of eligibility.

Medicare always starts the first of the month, usually the month of your 65th birthday. There are ALWAYS exceptions with Medicare, but that is when most individuals become eligible. If your birthday is the first of the month, your eligibility begins the first of the month before your birthday month.

If you are younger than 65 and are now eligible for Medicare for any reason, your medical coverage is the same. There are almost always no pre-existing condition limitations for Medicare coverage. There are some limitations to Medicare pre-existing conditions and they are for automobile accident coverage. If you are receiving medical care due to an automobile accident, that automobile insurance coverage will be in front of Medicare as long as your claim is active and paying. The automobile insurance coverage usually has a maximum spending, so if and when that is reached, Medicare would step in and cover those conditions.

Another situation like that is for Worker’s Compensation claims. Those benefits always pay first and Medicare is secondary. Once that case is closed or has reached its limit in some way, Medicare will step in and cover those conditions.

These two exceptions are the only two that I have seen happen, but there could be others. Of course if you have Current Employee coverage, that is usually in front of Medicare, but you stated you are retired and not working at this time.

This means that when you start on Medicare, you stay with all the same doctors and hospitals that you have seen, for all those conditions. You will just start with a new insurance payer for those medical bills.

Medicare does not disallow medical bills because you started on Medicare after your diagnosis. Medicare adopts all those diagnosis when it takes over your coverage.

There are some additional rules that apply to other insurance products related to Medicare. I will cover some of these now, as they apply to our local area. If you stay in original Medicare and sign up for a Medicare Supplement plan (Medigap) within a short period of time (63 days) of Medicare eligibility, the Medicare Supplement Plan will also have no exclusions in coverage. If you stay with original Medicare and choose not to enroll in a supplemental plan or an alternative within 63 days, then most companies include a six month pre-existing clause. To put this in a time line to make it more clear: If you received Medicare May 1 and enroll in a Medicare Supplement to begin by July 1, you will have no exclusions. If you begin Medicare May 1 and then don’t choose an additional Medicare Supplement Plan until Dec. 2, you will have full Medicare coverage, but your Medicare Supplement may have a six month pre-existing exclusion. I use the word “may” because most companies have a six month pre-existing exclusion, some have two or three months and one has NO pre-existing exclusion at all. If you delay getting additional insurance when you first started Medicare, you may want to look into those Medigap plans with a shorter period or no pre-existing exclusion clause, as this could save you a significant amount of money.

If you become Medicare eligible and you decide to enroll in a Medicare Advantage Plan, there may be reasons you are not allowed to join. One reason is if you have End Stage Renal Disease. If you are now eligible for Medicare and already have End Stage Renal Disease, you are not allowed to join a Medicare Advantage Plan. You must stay with Original Medicare and then you can join a Medicare Supplement Plan to cover those costs left after Medicare pays its part. If you develop End Stage Renal Disease after you have signed up for this Medicare Advantage Plan, you can choose to stay with that Medicare Advantage plan or change back to Original Medicare and a Medicare Supplement Plan.

All of these rules are true for all individuals becoming eligible for Medicare. This includes those who are younger and getting Medicare due to a disability or medical condition. Many people believe that some Medicare rules only apply to those 65 and older and that those who are eligible due to a disability or medical condition have a different set of rules and that is not true. Once you are eligible for Medicare, the enrollment rules are basically the same for everyone.

To contact Janell Sluga, GCMC with questions or concerns, please call 720-9797 or e-mail her at janells@lutheran-jamestown.org.