Answering Medical Underwriting Eligibility Questions for a Medicare Supplement Plan (Medigap): What to Know
Key takeaways:
Medical underwriting is a health test that helps insurers decide whether they want you as a customer and, if so, how much to charge you.
If you have “guaranteed issue rights” or a “trial right,” an insurance company is required to sell you a Medigap policy and cover all of your pre-existing conditions without charging you more. This means you’re not subject to medical underwriting. Otherwise, you can be denied coverage because of certain pre-existing conditions.
You have guaranteed issue rights during your one-time, 6-month Medigap open enrollment period. You may also have that status if you have other special circumstances.
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If you have original Medicare, you can buy a Medigap insurance supplement to help you cover some or all of your out-of-pocket costs. If you are age 65 or older and get Part B when you first sign up for Medicare, you will start your one-time, 6-month Medigap open enrollment period.
During that window, you are eligible to buy any Medigap supplement plan available in your state. You can’t be denied coverage for pre-existing conditions — no matter how healthy or sick you are at the time. You also generally have access to more plans and better prices during your Medigap open enrollment period.
If you have Medicare Advantage (MA) coverage, you can’t buy a Medigap plan.
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You could face medical underwriting, or questions about your health, if you try to buy a Medigap plan outside your 6-month Medigap open enrollment period. We’ll cover what that entails, as well as situations outside of open enrollment where you will not have to go through underwriting.
What is medical underwriting?
This risk assessment can include health questions and, sometimes, a health exam. At the end of the medical underwriting process, a Medigap plan can accept you, accept you and charge more, or deny you coverage.
There are certain times outside of your Medigap open enrollment period when you have “guaranteed issue rights” or other “Medigap protection” (more on this below). That means you can’t be denied Medigap coverage and won’t be subject to medical underwriting. Also, some states have more generous or different Medigap open enrollment periods beyond the 6 months after you are both age 65 and enrolled in Part B.
Can a Medicare supplement plan charge you more for pre-existing conditions?
If you are within your initial Medigap open enrollment period, or have guaranteed issue rights or a trial right, you can’t be charged more for pre-existing conditions. Otherwise, your pre-existing conditions can be a factor in how your premium is calculated.
What are guaranteed issue rights?
Guaranteed issue rights are times you can’t be denied access to a Medigap plan because your health coverage changes, such as losing other benefits. If you have guaranteed issue rights, an insurance company is required to sell you a Medigap policy and cover all of your pre-existing conditions without charging you more. This means you won’t be subject to medical underwriting.
5 common guaranteed issue rights circumstances
Guaranteed issue situations | You have the right to buy | You can or must apply for a Medigap policy |
You have a Medicare Advantage plan that is leaving Medicare or stops services in your area — or you move out of the plan’s service area. | Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state. You only have this right if you switch to original Medicare. | 60 days before the date your MA plan coverage ends and no more than 63 days after your MA plan coverage ends. (Medigap coverage doesn’t begin until your MA coverage ends.) |
You have original Medicare and your secondary plan — an employer group health plan (including retiree or COBRA coverage) or union coverage — has coverage that’s ending. (You may have additional rights under state law.) | Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state. You only have this right if you switch to original Medicare. If you have COBRA, you can buy Medigap right away or wait until your COBRA coverage ends. | No more than 63 days after the latest of these 3 dates: • Date your current coverage ends • Date on any notice you receive telling you that your coverage is ending • Date on a claim denial, if this is the only way you find out your coverage ended |
You have original Medicare and a Medicare SELECT plan, a type of Medigap plan sold in some states that requires you to use certain providers for full benefits — and you move out of the Medicare SELECT plan’s service area. Contact the Medicare SELECT company for more information about your options. | Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state or the state where you’re moving. | 60 days before your coverage ends and no more than 63 days after your coverage ends. |
You lose coverage because your Medigap plan’s company goes bankrupt or some other reason that’s not your fault. | Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state. | No more than 63 days after your Medigap coverage ends. |
You leave your MA plan or drop a Medigap policy because the company didn’t follow rules or misled you. | Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state. | No more than 63 days after your coverage ends. |
*Note: Plan C and Plan F are no longer available to people new to Medicare on or after January 1, 2020. But if you were eligible for Medicare before January 1, 2020 and haven’t enrolled, you may be able to buy Plan C or Plan F. People new to Medicare on or after January 1, 2020 have the right to buy Plan D and Plan G instead.
What is a trial right?
A “trial right” is your chance to try Medicare Advantage without losing the option to switch to original Medicare and buy a Medigap plan. This means you won’t be subject to medical underwriting. There are two types of trial right situations.
Trial right situations | You have the right to buy | You can or must apply for a Medigap policy |
|---|---|---|
You joined a Medicare Advantage or Program of All-Inclusive Care for the Elderly (PACE) when you were first eligible for Medicare and in the first year of enrollment, you want to switch to original Medicare. | Any Medigap plan that is sold in your state.* | 60 days before your coverage ends and no more than 63 days after your coverage ends. Your rights may last for an extra 12 months under certain circumstances. Contact your state insurance department for more information. |
You dropped a Medigap policy less than a year ago to join your MA plan or to switch to a Medicare SELECT plan for the first time — and you want to switch back to original Medicare with Medigap coverage. | The Medigap plan you had before joining the MA or Medicare SELECT plan — if the same company you had before sells the policy. If that policy isn’t available to you, you can buy Medigap Plan A, B, C*, D*, F*, G*, K, or L that is sold in your state. | 60 days before your coverage ends and no more than 63 days after your coverage ends. Your rights may last for an extra 12 months under certain circumstances. Contact your state insurance department for more information. |
*Note: Plan C and Plan F are no longer available to people new to Medicare on or after January 1, 2020. But if you were eligible for Medicare before January 1, 2020 and haven’t enrolled, you may be able to buy Plan C or Plan F. People new to Medicare on or after January 1, 2020 have the right to buy Plan D and Plan G instead.
What eligibility questions will you be asked when you enroll in a Medicare supplement plan?
Underwriting starts with some standard questions. Depending on your answers to these questions, you may be denied coverage immediately.
If you pass this initial test, you may be asked for additional information. You also may be asked to take a physical at a facility chosen by the insurance company. Based on the findings, the insurer may reject you. Or they may agree to sell you the plan with or without restrictions.
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They could charge you more — sometimes lots more — than they would have if you had signed up during your Medigap open enrollment period. And they may refuse to cover some medical conditions you have for a specified period, often for 6 months.
Here are four broad issues that many — but not all — insurance companies may consider when they underwrite.
Height and weight: If you are what the insurance company considers underweight or overweight, you could be denied coverage.
Prescription medications: You may be asked to sign a release that allows the insurance company to ask your physician and your pharmacy which medications you take. You could be denied coverage if you take prescriptions associated with conditions that have costly care.
Chronic conditions: If you have a chronic condition such as diabetes that the insurance company considers “under control” for a certain amount of time, you could be offered coverage. Otherwise, you could be denied for uncontrolled diabetes or other chronic conditions.
Disqualifying conditions: Some insurers have automatic disqualifiers, which we’ll discuss next.
Disqualifying conditions
Though not a complete list, here are some of the conditions or circumstances that can make you ineligible for Medigap coverage:
Amyotrophic lateral sclerosis (ALS) and other neurodegenerative disorders such as Parkinson’s disease, or multiple sclerosis (MS)
Cancer, including melanoma, leukemia, Hodgkin’s disease, or lymphoma
Chronic obstructive pulmonary disease (COPD) and/or emphysema
Cirrhosis of the liver
Congestive heart failure
Diabetes in an advanced stage
Inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis
Lower-extremity conditions such as diabetic neuropathy and peripheral vascular disease
Osteoporosis with fracture
Recent or frequent hospitalizations
Residency in a nursing home
Transplant, including bone marrow and/or organ
Milliman, a worldwide provider of actuarial and risk management services, provides this longer list of potentially disqualifying conditions. But they also warn insurers not to lose business by being too picky. So, even if you have a condition on any of these lists, consider applying anyway.
How to answer underwriting questions for a Medicare supplement plan
Here are some things you can do to make answering underwriting questions easier and persuade a Medigap plan that you are honest and have an understanding of your health.
Be prepared to outline your family medical history. If you can avoid saying “I don’t know” or just leaving things blank, you’ll be more persuasive.
Gather information. Know the dates and details of your past health conditions and treatments.
Identify members of your care team. Know the names, addresses, and phone numbers of doctors and other professionals who have treated you in the last few years.
Have copies of medical records. For example, if you had cancer in the last 5 years, be prepared to prove how long you have been in remission.
Take care of procedures you’ve been putting off. If you have pending surgeries or other treatments, have them done before you apply.
Stay away from marijuana. Some insurance companies will reject applicants who use marijuana, even when it is legal where they live.
Can you avoid the medical underwriting process?
Yes, you can avoid the medical underwriting process by enrolling during your Medigap initial open enrollment period.
What can you do if you are denied Medigap coverage?
Here are some steps you can take if you are denied Medigap coverage:
Call 1-800-MEDICARE (800-633-4227).
Talk to a knowledgeable Medigap salesperson where you live.
Appeal the decision. Each Medigap insurer has its own appeal process. Insurance departments in each state and Washington, D.C. can receive and investigate your complaint. These agencies can also help you file an appeal.
The State Health Insurance Assistance Program (SHIP) offers free access to trained, unbiased benefits counselors who can guide you on Medicare and Medigap issues.
Consider a Medicare Advantage plan, though you may be limited to certain healthcare professionals and face prior authorizations. But if your share of costs is your top concern, you will have an annual out-of-pocket spending maximum.
The bottom line
If you are age 65 or older and get Part B when you first sign up for Medicare, you can join a Medigap plan without medical underwriting during your one-time, 6-month Medigap open enrollment period. This is the best way to ensure you have access to all Medicare supplement plans available in your state at the lowest cost.
If you want to switch from Medicare Advantage to original Medicare or if you lose your Medigap coverage, you may qualify for guaranteed issue rights or a trial right. These allow you to buy a Medigap plan despite pre-existing conditions and without undergoing medical underwriting, or being charged more.
If you need help or get denied, reach out to a knowledgeable Medigap salesperson or a SHIP counselor — or call Medicare’s toll-free number.
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References
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Clark, K., et al. (2020). Medicare supplement underwriting issue brief #1. Milliman.
HealthCare.gov. (n.d.). Medical underwriting.
Kunkle Roberts, D. (2023). Can I pass Medigap underwriting? Boomer Benefits.
Malzone, L. (2023). Conditions that may cause a Medigap denial. Medigap.com
Malzone, L. (2023). Medicare supplement underwriting questions. Medigap.com
Medicare.gov. (n.d.). Get ready to buy.
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National Institute of Diabetes and Digestive and Kidney Diseases. (2018). What is diabetic neuropathy?
