No Pre X, Guaranteed Issue for Medicare Part D Prescriptions Rx!

Medicare A & B

Medi Gap

or Medicare Advantage!

I’m new to Medicare and take several Rx for pain, asthma and a few other conditions.

I heard that Part D makes one wait 6 months to a year to get coverage for the medications to cover a pre-existing condition.

So, why should I bother getting coverage?

 

There is no waiting period or pre-existing condition clause for Medicare Parts A Hospital, B Doctor Visits, C Medicare Advantage, or D Rx.

 

Medicare Supplements do have a 6 month look back period for Pre X, which is CLEARLY stated in the first paragraph on Page 15 of Publication 02110 Choosing a MediGap Policy.   California is more liberal though!
 
However, Medicare Parts A & B will still pay. BUT look at paragraph 5, if you buy during a guaranteed issue period, there is no pre-x!

 

Since you just got Part B you may have a guaranteed issue period for Part D, see publication # 11219 Medicare C & D enrollment periods. We need to get a copy of your Medicare ID card to verify when, why and how you got Part A & B. More on Part A & B enrollment periods.

I’ve looked at looked and don’t find anything that says exactly that there is no pre – x other than every seminar and training that I’ve ever seen. However, there is NOT a single brochure, policy, evidence of coverage, etc. that says that there is. A pre-existing condition clause would have to be listed in the exclusions and limitations to be enforceable!

 

Check these links and publications:

 

CA Health Care Advocates on Part D

Our introductory page on Part D Rx

Medicare’s Guide to Prescription Drug Coverage Publication # 11109

Blue Cross Evidence of Coverage – 124 pages, if this alleged exclusion isn’t here, where could it possibly be?

While every company has limitations on formulary – what Rx they cover and co-pays for different tiers of Rx, that is not a Pre X clause.

Here’s a reply from CA Health Care Advocates

The prohibition against using a pre-existing condition exclusion or waiting period for Medicare Parts A, B, and D is most likely in the Social Security Act that established the Medicare program. Whatever that is would have been applied to Part D when it was enacted if there wasn’t a separate requirement or prohibition.

But you are right that it isn’t specifically mentioned as a standard feature. Exclusions or limitations in Medicare Advantage programs probably build on that same concept so it probably isn’t specifically mentioned.

I’ve never looked for it because we know companies can’t impose it as a matter of law on A, B or D.

I don’t find a pre-x clause in the law Section 1814 Conditions & Limitations

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BE CAREFUL OF THE SNAFU'S!!!

The “Total Yearly Cost of Care” does not provide personalized or transparent information. For example, when a consumer inputs or changes personal data, such as drug information, his or her total estimated costs do not change. This is not mathematically possible based on the plan benefits. Additionally, the tool does not share what is included in the total cost. As a result consumers will likely see the total cost and assume they are receiving a personalized and tailored estimate which may not be accurate.

The estimated total yearly cost of care is flawed. On a plan that has reduced benefits year over year, the expectation would be that the “estimated total yearly costs” would increase. However the tool is inaccurately estimating the consumer’s costs will decrease. It doesn’t make mathematical sense. For consumers on a fixed income and cost conscious, this could be detrimental to their situation.

Most supplemental benefits are not included in the total yearly cost of care. Over the past several years supplemental benefits have expanded and provided members with options that not only treat, but prevent illness and increase quality of life. We know the high value of benefits such as vision, dental and hearing to our consumers, and they are a key way we are partners in care with our members. Some of the benefits that are not included are:

Transportation lists copay but not number of rides.

Eyeglasses list copay but does not share if benefit covers frames, lenses or contacts.

Wellness Programs include a long list of possible items including fitness, nurse hotline, Personal Emergency Response and telehealth, that can’t be lumped into a single “covered” or “not covered” benefit.  Excerpt from UHC Agent Memo  * Forbes GAO 7.2019 Report

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