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Can they Deny Medicare Part C: Can You Be Turned Down by a Medicare Advantage Plan?

October 18, 20238 min read

Medicare Advantage Plans are a popular alternative to Original Medicare, offering all the same Part A and Part B benefits along with extra perks like prescription drug coverage and dental care. But if you have pre-existing health conditions, you may wonder if you can be denied enrollment in a Medicare Advantage Plan or have treatment restricted.

The short answer is no – Medicare Advantage Plans cannot turn applicants down due to pre-existing conditions. However, they can limit certain services and provider choices which could impact care for an ongoing health issue. Understanding Medicare Advantage enrollment rights and coverage nuances is important when evaluating private insurance plans.

Medicare Advantage Plans Must Accept Pre-Existing Conditions

One significant protection provided by Medicare Advantage Plans is guaranteed eligibility regardless of your health status or pre-existing conditions.

Some key facts:

·        Plans cannot refuse your enrollment application based on pre-existing conditions or health history.

·        There are no waiting periods before pre-existing conditions are covered. Coverage begins as soon as your Medicare Advantage Plan effective date.

·        Plans cannot charge you higher premiums due to pre-existing health problems. All members pay the same rates.

·        Your benefits for any medical services cannot be excluded because of a pre-existing condition.

·        Plans cannot cancel your coverage mid-year if you get sick or need expensive care related to a previous issue.

In short, Medicare coverage Advantage Plans must take all comers and provide the full slate of benefits regardless of your personal health profile. Denying enrollment or benefits based on your pre-existing conditions is prohibited.

Beware of Plan Network Limitations

While a Medicare Advantage Plan can't exclude your pre-existing condition outright, some coverage limitations can still occur depending on the plan's provider network and treatment protocols.

For example, an Advantage HMO plan may only approve surgery at certain in-network hospitals. Or they may require trying specific therapies first before authorizing a different approach. This could limit options for a pre-existing problem requiring specialized treatment.

PPO health insurance plans with out-of-network coverage provide more flexibility to every beneficiary. But seeing non-network providers results in higher out-of-pocket costs for you.

Make sure to research a plan's providers carefully if you have a pre-existing condition that needs ongoing care management. Look for robust networks and minimal treatment restrictions to prevent problems getting the care you need.

Switching from Medicare Advantage to Medigap Carries Risk

Another pre-existing condition consideration involves your ability to switch from Medicare Advantage to Medigap coverage in the future.

Medigap Plans supplement Medicare Part A and Part B costs, reducing out-of-pocket expenses significantly compared to Medicare Advantage. But obtaining Medigap with pre-existing conditions can be difficult depending on timing.

During your open enrollment period when first signing up for Medicare, Medigap Plans cannot deny you coverage or surcharge premiums based on health history. But if you want to switch from Medicare Advantage to Medigap later, medical underwriting may exclude pre-existing conditions or make coverage unaffordable.

One strategy is enrolling in a Medigap Plan upfront when first eligible even if sticking with Medicare Advantage temporarily. This guarantees future Medigap access regardless of health changes down the road.

Shopping Smart with Pre-Existing Conditions

Picking the right Medicare Advantage Plan when you have pre-existing conditions requires diligence. Make sure to:

·        Confirm all your medical providers participate in-network to continue care.

·        Review drug formularies to ensure needed prescriptions are covered.

·        Understand referral and prior authorization requirements for specialty treatment.

·        Know your costs for out-of-network services if you want multiple opinions or options.

·        Consider supplemental Medigap coverage in case you need to switch plans later.

While an Advantage Plan can’t deny you outright for pre-existing conditions, limitations still exist. Do your homework to find coverage aligning both your health and financial needs for the long haul.

Why Medicare Advantage Appeals to Seniors with Pre-Existing Conditions

Medicare Advantage Plans have become quite popular among seniors with pre-existing medical issues. Features that appeal to this demographic include:

Guaranteed eligibility – Private Medigap Plans can exclude pre-existing conditions for up to 6 months and deny applications. But Medicare Advantage must accept all applicants regardless of health.

Low premiums – Advantage Plans typically have premiums of $0 to $100 per month only. No penalties apply for health conditions.

Annual out-of-pocket maximums – Once you hit a plan’s spending cap for covered care, you pay nothing more for the year.

Prescription drug coverage – Most plans include Part D with copays for medications. No need to buy separate drug coverage.

Extra benefits – Many plans include dental, vision, hearing, and other perks lacking in Original Medicare.

The financial protections Medicare Advantage offers make it an attractive option for those managing chronic conditions. Shop carefully and Medicare Advantage can provide solid coverage despite pre-existing issues.

Drawbacks of Medicare Advantage for Pre-Existing Conditions

While Medicare Advantage Plans appeal to many with pre-existing conditions, potential drawbacks do exist:

·        Network restrictions – Your choice of providers and facilities may be limited depending on plan type.

·        High copays – Frequent office visits and medications can mean high spending until you reach the plan out-of-pocket maximum.

·        Prior authorizations – Seeking specialist care or durable equipment for chronic issues often requires added plan approvals first.

·        Changing plan benefits – Insurers can alter details like provider networks, drug coverage and copays yearly.

·        No supplemental coverage – You cannot also have a Medigap Plan to help cover Medicare Advantage costs.

·        Limited plan choices – Some rural areas may only have one or two Medicare Advantage options available.

Understand how your pre-existing conditions could be impacted by these Medicare Advantage structural factors before signing up.

Key Points on Pre-Existing Conditions and Medicare Advantage Enrollment

In summary, here are some of the key facts to know regarding applying for a Medicare Advantage Plan if you have pre-existing health conditions:

·        Medicare Advantage Plans cannot legally reject your enrollment application or charge you more due to pre-existing conditions.

·        However, plan provider networks and treatment protocols can limit options for where and how you receive care.

·        Joining a Medigap Plan when first eligible for Medicare safeguards access later if you need to exit Medicare Advantage.

·        Pre-existing conditions can prevent enrolling in affordable Medigap policies if you wait too long.

·        Choose Medicare Advantage Plans carefully to ensure adequate provider choice and coverage for your conditions.

·        Weigh the appeal of low costs against potential plan restrictions that could impact your care quality and choices.

Carefully evaluating how Medicare Advantage Plans approach pre-existing conditions allows making an informed enrollment decision. While outright denial of coverage isn't allowed, factoring in benefits, provider access, prescription coverage, and costs aids in selecting advantageous coverage you can rely on.

We’re Here to Help

You do not have to spend hours reading articles on the internet to get answers to your Medicare questions. Give the licensed insurance agents at Bourgeois Insurance a Call at (985) 803-8999. You will get the answers you seek in a matter of minutes, with no pressure and no sales pitch. We are truly here to help.


When does a Medicare Advantage Plan deny coverage?

 A Medicare Advantage Plan may deny coverage in certain situations, such as when the requested service or treatment is not deemed medically necessary or when it is not covered under the plan's benefits.

Can a Medicare Supplement Plan deny coverage?

 No, Medicare Supplement Plans, also known as Medigap Plans, cannot deny coverage for pre-existing conditions if you enroll during your Medigap open enrollment period.

What is the Medicare Advantage open enrollment period?

The Medicare Advantage open enrollment period is a time when you can switch from one Medicare Advantage Plan to another or switch from a Medicare Advantage Plan back to Original Medicare. It typically occurs from January 1 to March 31 each year.

Can Medicare Advantage Plans deny coverage for pre-existing conditions?

 Medicare Advantage Plans are not allowed to deny coverage for pre-existing conditions. They are required to cover all services covered by Original Medicare except for hospice care.

What should I do if my Medicare Advantage Plan denies coverage?

 If your Medicare Advantage Plan denies coverage for a service or treatment, you have the right to appeal the decision. Contact your plan or a Medicare Advantage representative to get more information on the appeals process.

Can insurance companies deny coverage under a Medicare Advantage Plan?

 Yes, insurance companies offering Medicare Advantage Plans can deny coverage in certain circumstances, such as if the requested service is not medically necessary or not covered under the plan's benefits.

Can I be denied a Medigap Plan?

 Insurance companies are allowed to deny you a Medigap Plan if you have a pre-existing condition, except during your Medigap open enrollment period or guaranteed issue rights.

Can Medicare Advantage Plans deny coverage for prescription drugs?

 Medicare Advantage Plans are required to offer prescription drug coverage, but they may have a formulary that determines which drugs are covered. If a specific drug is not listed in the plan's formulary, it may be denied coverage.

Are there any circumstances where Medicare Advantage Plans can deny coverage?

 Medicare Advantage Plans may deny coverage if the requested service or treatment is not deemed medically necessary, not covered under the plan's benefits, or if you have not followed the plan's prior authorization requirements.

Can I be denied coverage when signing up for Original Medicare Plan and Medicare Advantage?

 Medicare Advantage Plans cannot deny you coverage based on your health status when you are initially enrolling in a plan, as long as you meet the eligibility requirements for Medicare.

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