If you switch your Medigap plan or miss your Open Enrollment Period for a Medicare Supplement, it’s likely that Medicare Supplement underwriting will be required.
Maybe you’ve been on your Medigap plan for a while, and the rate has gone up a few times. Maybe you originally signed up for Plan F and now you feel the Plan G would offer additional savings.
Most likely you’re wondering if you can be turned down for Medicare Supplement insurance, the answer is that in most states, yes you can be denied coverage.
Medicare Supplement Underwriting Questions
In most states, you need to answer health questions and pass underwriting to get approved for new coverage. While medical underwriting can cause some stress, there are thousands of people that pass underwriting to change plans each year.
Let’s dive into information about which situations are likely to result in approval and when you may face hurdles to successfully change plans. This information will help you understand if you’re Medigap eligible.
Guaranteed Issue Means No Health Questions
Each Medicare Beneficiary gets an Open Enrollment Period for Medicare Supplement insurance when they turn 65 and first activate their Part B.
If you’ve done research on Medigap plans, you already know that this 6-month enrollment window means you get to apply for a Supplement without answering health questions.
There are other situations in which you’re guaranteed the right to buy a comprehensive Medigap policy without underwriting, this is called Guaranteed Issue or “GI”.
Here are some Guaranteed Issue examples:
- You are leaving coverage, such as employer coverage at a large company, within the last 63 days.
- Medicare Advantage trial period, within 12 months of you first enrolling in a Medicare Advantage plan you can dis-enroll and get Medigap instead.
- If you move out of your plans service area and you have a Medicare Advantage plan or Medicare Select policy.
Each of these scenarios offer beneficiaries a small window to purchase a Medigap policy without answering any health questions.
There are other possible circumstances that could result in a GI period, talking to an insurance agent that specializes in Medicare is your best option for uncovering situations where you might qualify for GI.
Medigap’s Birthday Rule States
This does require that you have a Medicare Supplement policy currently in place to qualify. If you talk to your agent, they can obtain quotes for your same or lesser plan to see if lower rates are out there for you.
If you find a good deal, the application process is quick and easy because there is no medical underwriting.
Washington allows Medigap eligibility year-round, this means that anyone can apply anytime and get coverage. This also means that rates in Washington for Medicare Supplements are much higher.
Medicare Supplement Underwriting
Now that you’re basically an expert with GI situations, let’s talk about HOW the insurance companies underwrite.
Basically, each insurance company has at least one page of health questions included in its Medigap application. Some of the questions ask if you’ve EVER had a certain condition, and others ask about a recent time period. Commonly, questions ask about the last two years of your health history.
You’ll need to answer NO to some or all the health questions as indicated on the applications. When you answer YES to a question it can result in an automatic decline for most carriers. This means you’re not eligible for the coverage and there is no need to apply.
Depending on state laws and specific carrier exceptions, it’s best to talk to an agent about any possibilities.
Through the next sections I’ll cover some sample questions from actual Medigap carrier applications.
Minor Health Conditions May Result in Approval
If you are fully healed and done with treatment, certain injuries are no issue. You will also notice the insurance companies don’t care if you had the flu twice last year or seasonal allergies.
High blood pressure and cholesterol are also an unlikely issue, if they’re not occurring alongside another more serious condition.
For example, minor arthritis is no problem, but a more serious form of rheumatoid arthritis would cause a decline.
The Body Mass Index (BMI) is also usually more relaxed on Medigap plans than on other forms of insurance, like life insurance. Carrying a few extra pounds isn’t an issue if you aren’t morbidly obese.
Each company has underwriting guidelines and your agent can check your BMI to the company guidelines this way you don’t spend time applying when you’d otherwise be declined.
Finish Upcoming Pending Surgeries and Treatments First
Of course, there are potentially declinable situations, and expensive pending procedures top the list. It’s obvious that no insurance company wants to cover you just before a costly test or major surgery.
Carriers want you to get your treatments done with your old carrier before you apply for new coverage.
Even if your upcoming surgery is not life threatening, like gall bladder removal, you will still need to wait to apply. It’s best to complete the surgery and any follow-up visits or therapy and then apply for the new carrier.
Example question from a major carrier’s applications: “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?”
There are carriers that also ask for a window of time clear after a major surgery, like a knee replacement. Since hardware problems are possible, they may ask you wait a year or two before submitting your application.
These kinds of requirements vary and it’s best to ask your agent which carriers offer you the best chance.
You’ll Need to Wait if You had Recent Major Care
If you’re receiving home health care or if you’ve been hospitalized 2 or more times in the last 2 years, it’s likely the carrier will decline you right on the application. If you live in a nursing home, you may not be eligible.
People rarely go from a nursing home or assisted living facility back to living on their own, you may need to stick with your coverage for the rest of your life.
Sample question from a carrier: “Are you currently hospitalized, confined to a bed, in a nursing facility or assisted living facility, receiving home health care or physical therapy?”
Cancer is a common concern among applicants. Most carriers want at least 2 years cancer-free and in remission before they will consider you. If you’ve had a recent surgery or you are going through any treatments, you’ll need to wait a few years before you apply.
Keep Your Coverage if you have a Chronic, Incurable Condition
There are plenty of illnesses that are treatable but incurable, if you have a serious illness that requires forever treatment, you’ll find that the questions on most Medicare Supplement applications will exclude you.
Common examples would include:
- Chronic lung disorders
- Immune disorders such as RA, MS, Lupus, or AIDS
- and nervous system disorders such as Parkinson’s
If you have osteoporosis and fractures this could be problematic. Insurance companies know these conditions will require a lifetime of care costs.
Heart disorders like arterial and vascular diseases, history of heart attack and/or strokes, stents, pacemakers and congestive heart failure could also prevent you from changing carriers.
Many carriers will decline for rhythm defects or valve problems. In most circumstances’ kidney failure and/or organ transplants can cause a decline.
Depending on the carrier and how they phrase the related question on their application, you may or may not be able to pass the Medicare Supplement underwriting.
An example of a borderline condition would be diabetes. If you only take an oral medication or you take less than 50 units of insulin, you should be approved.
With diabetes, carriers look at relative conditions. So, if you have diabetes and high blood pressure with cholesterol or neuropathy, it’s much harder to get approved. If you have diabetes without any related conditions, you should be able to change carriers.
Sample question: “Do you have diabetes with hypertension requiring 3 or more hypertension medications to control or diabetes requiring more than 50 units of insulin daily to control?”
Another example would be mental health conditions. Typically, seeing a therapist or taking a mild anti-depressant isn’t an issue. When you have a more chronic mental disorder that can cause a decline.
Sample question: “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?”
Declined for Medications
Prescription history records are available to Medigap carriers. On your application, you must agree to allow the carrier access to these records.
Once the carrier pulls the report they will look to see if there are any prescriptions in your record that may indicate a declinable condition. It’s important to be honest and try to remember all the medications that you were recently prescribed.
Of course, Medigap carriers also have a list of medications that mean you’re automatically declined. These medications are ones that treat major or chronic illnesses.
Basically, if you take these medications you’re indicating that you have a health condition that might be expensive for the carrier to treat.
Pain medications can sneak up on you. If you took a short-term round of hydrocodone while recovering from surgery, the insurance company won’t consider this a problem. If you’ve been taking it for years, then that indicates a potentially costly problem.
Medigap carriers don’t like to take a chance on this. Other problematic pain medications include fentanyl, morphine, oxycodone and oxycontin.
Here is a list of some covered drugs covered by Medicare Part D.
Most people don’t know what is in their medical records. Think carefully; if your doctor told you that you are pre-diabetic, ask him what is written in your file. Did your doctor sugar-coat the health condition in his discussion with you?
He may have told you that your pre-diabetic, but what matters is what is in your file. If your chart says diabetes, that is what the carrier will include in your assessment. If you don’t know, ask your doctor.
Submitting a Medicare Supplement Application
Here at MedicareFAQ, we have brokers that, when you’re 100% open with, can help you navigate to the most appropriate carrier with any specific health issues that you have. We will ask you this, so we know how we can best help you:
In the past 5 years, have you been diagnosed, received treatment for, or taken any prescribed medications for:
- Heart Attack or any heart issues such as a Pacemaker or Defibrillator
- Stroke or TIA
- AFIB (Atrial Fibrillation)
- Disabling Arthritis
- Stent Placement
- Prescribed any Blood Thinner medications
- Been advised to have any surgery that hasn’t been completed?
Even if you answer yes, this helps our brokers to find the most compatible plan and carrier for your needs. Talking to an expert can make applying for coverage simple.
Once the insurance company that is most suitable for you is identified, your application can be taken over the phone.
Switching supplements can take time, so you should apply for an effective date that is 2-3 weeks out. This will give the underwriting department plenty of time to complete your application.
You should expect an underwriter to call you, the phone interview is an important part of the carrier’s decision process.
Never Cancel Coverage Before New Coverage is Approved
This is very important, you should never cancel your current coverage before you are approved with your new carrier.
Your agent at MedicareFAQ will watch your pending application and notify you immediately, after you receive that call, then you can contact your old carrier to cancel that coverage.
Insurance agents cannot cancel prior coverage for you, this rule protects you and you should never assume your agent will cancel your old coverage for you.
There is no reason to have double Medigap coverage, once you’re approved, you’ll need to cancel your old coverage.
To contact an agent licensed in your area, simply complete our contact form here. Or, you can call the number above to speak to an agent now. They will be happy to help answer any questions you have regarding your Medicare benefits and medical underwriting questions.