Medigap Waiting Periods for Pre-Existing Conditions

By Kendra Knouff
eMedicareSupplements Senior Writer

The Waiting Period for Pre-Existing Conditions is Changing

Under regulations from the state of New York, the average six-month waiting period for pre-existing conditions required by most Medigap policies may be reduced or waived altogether. A pre-existing condition is a physical or mental condition that an individual has been diagnosed with and for which medical advice and/or treatment has been given six months prior to enrolling in a new health care plan.

Insurance companies providing Medigap coverage must reduce the waiting period for pre-existing conditions by the number of days the beneficiary received creditable coverage as long as there was no gap in coverage greater than 63 calendar days. For example, if an individual received creditable coverage for 173 days, the waiting period will be reduced by that amount (173 days).

Creditable coverage is provided by any of the following sources:

  • Health insurance coverage
  • Champus and Tricare health care programs for the armed forces
  • A medical care program of the Indian Health Service or of a tribal organization
  • A State health benefits risk pool
  • Federal Employees Health Benefits Program
  • A group health plan
  • Medicare (Credit for this type of coverage is only required if an application is submitted to Medigap in the initial six-month period a beneficiary is both 65 and enrolled in Medicare Part B)
  • Medicaid
  • A public health plan (Any plan established or maintained by a state, the U.S. government, a foreign country, or any political subdivision of a state, the U.S. government, or a foreign country that provides health coverage to individuals who are enrolled in the plan.)
  • A health benefit plan issued under the Peace Corps Act
  • Medicare supplement insurance, Medicare select coverage or Medicare Advantage Plan (Medicare HMO Plan)

Enrollment and portability provisions given by New York state are applicable to beneficiaries eligible for Medicare because of age or disability. They also apply to those suffering from end-stage renal disease.

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