Medigap underwriting is often required when you want to switch your Medigap plan.
Perhaps you’ve been on your Medigap plan for a while, and the rate has gone up a few times. Or maybe you originally signed up for Plan F, and now you are interested in the potential savings of Plan G.
It could even be that you are one of the unlucky few who missed your open enrollment window for a Medigap plan. Now you are wondering: Can you be turned down for Medicare supplemental insurance?
In most states, yes.
You’ll have to answer health questions and pass underwriting to get approved for a plan. This can create some anxiety about medical underwriting! Fortunately, hundreds of thousands of people pass underwriting to change plans each year.
Let’s explore which situations are likely to result in approval and which circumstances might result in roadblocks to successfully changing. This will help you better understand your Medigap eligibility.
Guaranteed Issue Situations – No Health Questions
Everyone gets an open enrollment period to enroll in Medigap when they turn 65 and/or first activate Part B. If you’ve been doing your research, you now know that this 6-month open enrollment window means you can apply without answering any health questions. It’s a one-time window though, and then it’s gone.
Fortunately, there are several other situations in which you are guaranteed the right to buy a comprehensive Medigap policy without underwriting. We call this Guaranteed Issue or “GI”. Here are a few common GI examples:
- Leaving other coverage, usually employer coverage at a large company, within the last 63 days.
- You tried a Medicare Advantage plan for the first time, and within 12 months you wish to dis-enroll and get Medigap instead.
- You have a Medicare Advantage plan or Medicare Select policy, and you have moved outside your plan’s service area.
In all of these situations, you have a small window to purchase a Medigap policy without answering any health questions.
There are a few other things that result in GI periods. Ask your insurance agent to check and see if any apply to you. Working with an experienced agent who specializes in Medicare is your best bet for uncovering situations where you might qualify for GI.
States with the Birthday Rule – the Lucky Exception
In California and Oregon, you can change your Medigap policy during the month of your birthday with no Medigap underwriting. You must have an existing policy in place to qualify. Have your agent run quotes for your same plan or a lesser plan to see if lower rates are out there. If so, completing the application is short and easy because there are no health questions.
There are also states like Washington where you have Medigap eligibility year round. Anyone can apply anytime and get covered. However, this is also what makes the rates for Medigap plans in Washington so expensive.
Medigap Underwriting: the Health Questions
Now that we’ve covered the GI situations, let’s talk about HOW the insurance companies underwrite. Each insurance company has its own application for Medigap. That application will include at least one page of health questions.
There will be questions about certain conditions that you have ever had, and there will be others where they ask about a recent period of time. It’s common to see questions about the last two years of your health history.
Generally you’ll need to be able to answer NO to some or all of the health questions as indicated on the application. Answering yes to a question results in an automatic decline with most carriers. You are not eligible for the coverage and do not need to even submit the application. There may be limited exceptions with a few carriers, depending on your state laws, so it’s always good to ask your agent about any possibilities.
The good news is that here at our agency, we find that about 75% or more of all underwritten applications get approved. So read our advice below and if you want to try an application but have a question first, you can ask me in the comments section below the article.
As you read through the following sections, I’ll give you some sample questions from actual Medigap carrier applications.
Sample Underwriting Question for Medicare Supplement Applications
When you are looking for a Medicare supplement, our team can really help to identify which carriers might be a good fit for you. They’ll know which carriers have underwriting questions that may be more lenient than another for certain health conditions. Nearly all applications will ask for information about ongoing conditions. For example:
In the past 3 years, have you been diagnosed with, received any treatment or been prescribed any medications for the following conditions:
- Internal Cancer
- Heart Conditions
- Atrial Fibrillation
- Stroke or Transient Ischemic Attack
- Chronic Obstructive Pulmonary Disease
- Rhemautoid or disabling arthritis
So now that you know the kinds of Medigap Underwriting questions you may be asked, let’s talk about how various health conditions or procedures could affect you.
Minor Health Conditions – Likely Approval
The first thing you’ll notice is that the health questions don’t concern minor things like seasonal allergies, or the flu. Likewise, they don’t really care if you had two colds last year or a urinary tract infection. Certain injuries are a non-issue as well, as long as you are fully healed and done with treatment.
Often things like high blood pressure and cholesterol are not an issue either as long as they are not occurring alongside another more serious condition. Minor arthritis is not a problem, but as you’ll see below, a more serious form of rheumatoid arthritis would cause a decline.
Body Mass Index (BMI) is usually more relaxed on Medigap plans than on other types of insurance, like life insurance. Carrying a few extra pounds is not a problem as long as you are not morbidly obese. Every carrier will have underwriting guidelines about this, so your agent can check your height/weight against the company’s guidelines to make sure you don’t apply if your BMI will cause a decline.
Pending Surgeries and Treatments – Finish them First
Now we’ll begin to move into potentially declinable situations, and expensive pending procedures top the list. Obviously, no insurance carrier wants cover you just before a costly diagnostic test or major surgery. Remember that Medigap carriers will pay for 20% of that surgery. They want you to get that done with your old carrier before you apply with them.
This is the case even if your pending surgery is for something non-life-threatening – such as endometriosis or a gall bladder removal. You will need to complete the surgery and any follow-up visits or therapy before a new carrier will consider you.
Here’s an example from a major carrier’s application: “Within the past 12 months, have you been advised by a medical professional to have treatment, further evaluation, diagnostic testing, or any surgery that has not been performed?”
Some carriers may also ask for a window of time clear after a major surgery, such as knee replacements. Since hardware problems can occur, they may ask you to wait a year or two before submitting your application. Requirements vary though. Be sure to ask your agent about which carriers questions offer you the best chance.
Recent Major Care – You’ll Need to Wait
Medigap carriers also ask questions about recent major care. If you are receiving home health care or have been hospitalized 2 or more times in the last 2 years, it is common for the carrier to decline you right on the application. Likewise, if you live in a nursing home, you may not be eligible. Since people rarely go from assisted living or nursing home back to living on their own, your current coverage may be the coverage you need to stick with for the rest of your life.
Example: “Are you currently hospitalized, confined to a bed, in a nursing facility or assisted living facility, receiving home health care or physical therapy?”
Many people also ask us about cancer. When it comes to a major life illness, such as cancer, the carriers usually want at least 2 years cancer-free and in remission before they will consider you. If you have had recent surgery or are still treating, you’ll need to wait a few years before you apply.
There is at least one major carrier that will consider people with cancer or other serious conditions, but will charge you a significantly higher rate for the coverage. Sometimes we find that your current carrier is cheaper than switching to a carrier that is “rated-up” for a major health condition.
Chronic, Incurable Health Conditions – Keep Your Current Coverage
Some illnesses are treatable but incurable. If you have a serious illness that will require treatment forever, you’ll find that the questions on most Medigap applications will exclude you. Common examples would be dementia, chronic lung disorders, immune disorders such as RA, MS, Lupus, or AIDS, and nervous system disorders such as Parkinson’s. Osteoporosis with fractures will also be problematic. The insurance company knows these conditions will require lifetime expensive care.
Major heart disorders might also prevent you from changing carriers. Arterial and vascular diseases, history of heart attack and/or strokes, stents, pacemakers and congestive heart failure are some examples. Many carriers decline for rhythm defects or valve problems. Kidney failure and/or organ transplants can cause a decline in most circumstances.
Borderline Conditions – Could Go Either Way
Some conditions are what we call borderline. Depending on the carrier and how they phrase the related question on their application, you may or may not be able to pass the Medigap underwriting.
Diabetes is an example of a borderline condition. If you take only oral meds or you take less than 50 units of insulin, you might be approved. With diabetes, carriers look at relative conditions. For example, if you have diabetes and high blood pressure with cholesterol or neuropathy, it is much harder to get approved than if you have diabetes without any related conditions.
Example Question: “Do you have diabetes with hypertension requiring 3 or more hypertension medications to control or diabetes requiring more than 50 unites of insulin daily to control?”
This is one condition where I always advise you talk to an agent because individual Medigap underwriting guidelines on this vary quite a bit. Your agent will know where you’ll have the best chance.
Another example would be mental health conditions. Generally, seeing a therapist or taking a mild anti-depressant is not an issue. However, the more chronic mental disorders can cause declines.
An example is: “Do you have now or in the last 2 years have you been treated for (including surgery) or advised by a medical professional to have treatment for major depression, bipolar disorder, schizophrenia, or a paranoid disorder?”
Auto-Decline Medications and Script Checks
Medigap carriers have access to national records regarding your prescription history. On your application, you must agree to allow the carrier access to these records.
When the carrier pulls the report, they will first look to see if there are any prescriptions in your record that may indicate a declinable condition. For example, if you take a blood thinner, the insurance company wants to know why. They’ll look closely at what other medications you take that could indicate significant health problems.
It’s important to be honest. Try hard to remember all meds you’ve taken recently. Think back over your medication history.
If your doctor once prescribed a medication for lupus, but you didn’t mention lupus on your application, that’s a red flag. You may not consider yourself to be “taking that medicine” but it still exists in your record, and you can be sure they’ll ask about it.
Auto-Decline Drug Lists
Carriers also have a list of auto-decline medications. These are medications that treat major or chronic illnesses. By virtue of taking these meds, you indicate a health condition that might be expensive for the carrier to treat.
Sometimes a certain mix of medications is problematic. If you take diabetes meds along with high blood pressure and cholesterol meds, you may be denied. Carriers will look at your history with those meds and see how recently your dosages have changed. Frequent or recent changes can work against you.
One set of medications that can sneak up on you are pain medications. If you took a short-term round of hydrocodone while recovering from a surgery, this usually won’t be a problem. However, if you have been taking it regularly, then that indicates an underlying and potentially costly problem. The Medigap carriers don’t usually like to take a chance on this. Similar problematic pain meds include fentanyl, morphine, oxycodone and oxycontin.
A Word about Medical Records
Something we’ve noticed over the years is that average people don’t always know what’s in their medical records. Think carefully about this. If your doctor has told you that you are pre-diabetic, ask him what is written in your file. Did your doctor sugar-coat that health condition in his conversation with you?
Perhaps he told you that you were pre-diabetic, but what matters is what he wrote in the file. If your chart says diabetes, that is what the carrier will include in its assessment. If you are unsure, ask your doctor before you apply.
Also, if a doctor prescribes a medication that you have no intention of filling, tell him that at the appointment and ask him not to prescribe it. Once it is prescribed, it’s in your medical record.
Submitting a Medigap Application
Once your agent has identified which insurance company you’ll apply with, she can usually take that application from you over the phone or by emailing you a printable application. You’ll complete the application and your agent will check to make sure that you have answered NO to all the questions that require a no.
Switching Medigap plans can take time, so I recommend applying for a future effective date that is a 2 – 3 weeks out. This gives the new insurance company plenty of time to complete underwriting and give you an answer before the coverage will take effect.
Your agent forwards your application to the Medigap underwriting department. An underwriter will call you. The phone interview is an important part of a carrier’s decision process.
Underwriters will usually have questions related to your medical records and prescriptions you’ve taken. Occasionally they may ask you to provide medical records if your doctor’s office is unwilling to forward them, but this is relatively rare.
Don’t volunteer any information more than what the underwriter asks you. Occasionally we see someone get declined for information that they voluntarily offered that was not an answer to a question asked by the underwriter. Use yes and no answers to questions whenever possible.
Don’t Cancel Until Your Medigap Eligibility is Confirmed
It’s important not to cancel any current coverage until after your agent notifies you that your application is approved. Here at Boomer Benefits, we watch the pending applications daily and notify our clients immediately. Once you received that call, you will always need to contact your old carrier to cancel that coverage.
Your insurance agent cannot cancel prior coverage for you. That rule exists to protect you. So never, ever assume that your agent is cancelling your old coverage for you. Many people have contacted us for help over the years who had actually enrolled in MORE than one supplement plan from different agents before they found us. There is NEVER any reason to have double Medigap coverage.
(If you need help with how to find affordable and reputable carriers, click the green box just below this text for our free report.)
The Dreaded Denial – What Now?
So if you submit an application and get denied, is that the end of the world? Does it mean that everyone else will deny you too? Not necessarily. Our team has great success with evaluating reasons for denial and examining other carriers to see where else you might have a chance. If there are no other carriers that are likely to accept you, we’ll tell you. Then you can decide if you want to keep your current coverage or look at other options like Medicare Advantage.
It’s worth mentioning here that the open enrollment period in the fall for Part D drug plans does not apply to Medigap plans. That period is NOT a time when you can apply for a new Medigap carrier and skip the health questions. If you can’t pass the underwriting because of health conditions, you will have a choice to make. You cankeep your existing policy or look into the Medicare Advantage alternative, which has fewer health questions.
Wouldn’t It Be Great to Have Someone on Your Side?
Going through Medigap underwriting can be a scary time. With Boomer Benefits, you don’t have to go it alone. We’ll choose the carrier where you have the best chance. If we believe you can’t pass Medigap underwriting questions right now, we’ll be the first to tell you.
Sometimes waiting a few months can make a difference. The worst thing is to be declined and be unsure whether you have any other options. Working with us means you’ve got someone to advise of your options. Learn more about out stellar Client Service Team here.