Medigap Pre-Existing Condition Waiting Period

Calendar Icon Updated January 15, 2019
Medicare

A Medigap policy (also known as Medicare Supplement Insurance) is an insurance policy offered by private companies to cover some coverage gaps of Medicare Part A and Part B (Original Medicare). For example, Medigap policies can pay for deductibles, coinsurance, and copayments, as well as some services that are not provided by Original Medicare, such as if you become sick while traveling overseas.

During the Medigap open enrollment period, which lasts for six months and begins on the first day of the month in which you’re both 65 (or older) and enrolled in Medicare Part B, the Medigap insurance company cannot make you wait for coverage to start—except under certain circumstances.

The Pre-Existing Condition Waiting Period

An insurance company generally isn’t allowed to make you wait for your Medigap coverage to begin, but it may be able to delay coverage if you have a pre-existing condition. (A “pre-existing condition” is a health issue or condition that you have prior to the date when the new insurance policy starts its coverage.)

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This waiting period is called a “pre-existing condition waiting period.”

How the Pre-Existing Condition Waiting Period Works

The insurance company can exclude coverage for the pre-existing condition if the condition was treated or diagnosed within six months before the coverage starts under the Medigap policy.

If you’re subject to a pre-existing condition waiting period, the insurance company can make you wait for up to six months before it will cover your out-of-pocket costs. Once the waiting period expires, then the Medigap policy covers the pre-existing condition. (Original Medicare will still cover the condition even during the pre-existing condition waiting period, though the Medigap policy won’t cover your out-of-pocket costs. This means you’ll be held responsible for the coinsurance or copayment.)

Avoiding or Reducing the Waiting Period

In some cases, you can either avoid or reduce a waiting period for a pre-existing condition. For example, if you are replacing particular types of health insurance that count as “creditable coverage,” the waiting period can be eliminated or shortened. (In general, if you had any other health coverage before applying for a Medigap policy, this will count as creditable coverage.)

In cases where you had at least six months of continuous creditable coverage without a break in coverage of more than 63 days, there is no waiting period.

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You can also avoid a waiting period if you buy your Medigap policy when you have a guaranteed issue right, which is also called “Medigap protections.” (Medigap protections are rights that you get in certain situations so that an insurance company is required by law to sell or offer you a Medigap policy, even if you have a pre-existing condition.)

You typically have a guaranteed issue right if your existing health coverage changes in some way.

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