BACKGROUND: Pre-existing multiple (two or more) long-term conditions (MLTCs) may negatively affect recovery after COVID-19. We investigated how pre-existing MLTCs, including different categorisation and patterns of MLTCs, affect one-year health outcomes after severe COVID-19. METHODS: Adults post-hospitalisation following COVID-19 were recruited during 2020 -2021. We compared recovery at one-year after discharge using adjusted multivariable logistic regression in 1:1 propensity matched adults (for age, sex, ethnicity, social deprivation, obesity, and smoking history) with and without pre-existing MLTCs. In adults with MLTCs, different categorisation such as number of conditions, number and types of body systems involved (e.g., respiratory, cardiovascular), and latent class analysis derived patterns of condition co-occurrence were assessed for their association with recovery at one-year. FINDINGS: 647 adults with MLTCs were matched with 647 adults without MLTCs (n=1294; 61.9% male, 79.6% of white ethnicity, median age 59 [IQR 52-67] years). The presence of MLTCs were associated with lower odds of feeling fully recovered (odds ratio (OR) 0.66 [95% CI 0.51 to 0.85], p=0.001). In those with MLTCs, recovery was negatively affected by number and type of body systems involved (e.g., respiratory (OR 0.49 [95% CI 0.34 to 0.69], p<0.001)) but not by the number of conditions (p>0.1). Four latent classes of MLTCs co-occurrence were estimated with different risks of recovery (p<0.01). INTERPRETATION: Adults with pre-existing MLTCs were 34% less likely to feel fully recovered at one-year after COVID-19 hospitalisation compared with adults without MLTCs. We describe prognostic classifications of MLTCs with future work needed to understand if they have prognostication in broader post-acute infection sequalae.