by Russell Noga | Updated August 14th, 2023
Are you switching Medigap plans or providers?
Did you miss the “Open Enrollment” period for Medigap plans?
If so, the Medigap provider might ask you to undergo “medical underwriting” when joining their scheme or switching plans.
Everyone who is enrolled in Medicare has a Medigap open enrollment period for 6 months when their Part B Medicare begins. Since private healthcare insurers in the United States offer Medigap policies, they have the right to require medical underwiring if you don’t take a Medigap plan during this period.
Medicare supplement underwriting eligibility questions determine your risk profile, allowing the insurer to judge whether it’s worth it for them to insure you. This post examines the criteria and questions surrounding medical underwriting and what to expect from the process.
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Medicare Supplement Plans – Benefits & Coverage
Medicare supplement plans offer benefits related to the plan your choose. The ten plans have different standardized benefits regulated by the CMS, a Federal agency. All Medigap plans provide the following benefits.
- Part A coinsurance and hospital costs for up to 365 days after using up Medicare benefits.
- Part A hospice care coinsurance or copayment.
- Part B coinsurance or copayment.
- Blood transfusion costs for the first three pints of blood.
Plans F*, G, and N offer additional Medicare Parts A & B benefits.
- Part A deductible.
- Part B excess charges (Plan N doesn’t cover these charges).
- Skilled nursing facility care coinsurance.
- 80% of emergency healthcare costs when traveling outside the US for 60 days. ($250 deductible and $50,000 maximum apply).
- Unlimited coverage for all out-of-pocket costs.
*Plan F is only available for seniors eligible for Medicare before January 1, 2020.
What Is Underwriting for Medicare Supplement Plans?
Medical underwriting involves the Medigap insurer asking you a set of questions about your current health status. The insurer uses underwriting to determine your “risk profile” for its Medigap scheme.
Your “risk” means if the insurer determines they’ll have to pay out more in treatments and care costs than they expect to make in premiums over your expected membership to its program. If you’re a high-risk beneficiary, the insurer will use the underwriting process to disqualify you from joining their Medigap scheme.
Underwriting Criteria for Medicare Supplement Insurance
Every insurer has a form of health-related questions included in your Medigap application to its scheme. Some questionnaires ask for details on your past health conditions; others only ask about your current status.
It’s common for carriers to ask questions relating to the last two or three years of your health history. However, some carriers may go as far back as five years into your health history when assessing your Medigap application and risk profile.
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Minor Health Issues Usually Result in an Approval
If you experienced the flu or other viral diseases during the year, it wouldn’t affect your application, and the insurer won’t ask you about it.
They might ask you about issues like high blood pressure and high cholesterol, but they’ll only deny you coverage if these issues occur alongside other conditions that might cause complications.
For instance, if you have arthritis, it’s not usually grounds for denying coverage, but rheumatoid arthritis could result in a denial of coverage.
Your Medical Records
Most applicants have no idea about their medical records and history. So, for instance, if your doctor diagnosed you as a pre-diabetic, they might list you as a high-risk for diabetes in your file or say you’re undergoing treatment to reverse the condition.
The scenarios are different, and if your chart lists you as diabetic, even though you’re pre-diabetic, it will influence your risk profile with the carrier.
Pending Treatments & Surgeries
If you have an upcoming surgery, it might result in denial of coverage by a Medigap provider.
Even if the surgery isn’t life-threatening, they’ll require you to apply after undergoing the procedure and not before to reduce their financial liability for the surgery or treatment.
Recent Major Health Services
Suppose you recently (in the last year) experienced more than two periods of hospitalization or received home-based healthcare services. In that case, the insurer may decline your application to join its Medigap scheme. Applicants living in nursing homes likely won’t experience acceptance to the insurer’s Medigap scheme.
Borderline Chronic Conditions
If you have diabetes or mental health disorders classified as “borderline chronic conditions,” the Medigap insurer might deny your application.
Chronic Conditions
Several chronic health conditions requiring lifelong treatment exclude you from the insurer accepting your Medigap application. Here are some examples of what the insurer considers chronic conditions.
- Chronic lung issues or disease.
- Dementia
- Immune deficiency disorders such as AIDS, RS, MS, or Lupus.
- Nervous system problems like Parkinson’s disease.
- Osteoporosis and related fractures.
- Organ transplants.
- Kidney failure.
- COPD
- Cancer
- Disabling Arthritis.
- Diabetes
- Heart disorders like previous heart attacks, stents, strokes, vascular and arterial diseases, pacemakers, congestive heart failure, rhythm defects, and valve problems.
Diagnosis or treatment of any of the following in the last five years.
- Heart problems requiring a Pacemaker or defibrillator.
- TIA or stroke.
- AFIB (Atrial Fibrillation).
- Use of blood thinners.
Declinable Conditions When Applying for Medicare Supplement Plans
The following conditions will also likely result in the insurer denying you a Medigap plan.
- Alzheimer’s Disease
- ALS
- Asthma (with 3 or more medications)
- Dementias
- Chronic Bronchitis
- Cystic Fibrosis
- Cirrhosis
- COPD
- Diabetes
- End-Stage Renal Disease (ESRD)
- Emphysema
- Fibromyalgia
- Hepatitis
- Multiple Sclerosis
- Kidney Disease requiring dialysis
- Mental/ Nervous Disorder
- Myasthenia Gravis
- Use of Supplemental Oxygen or Nebulizer
Drugs
Medigap insurers also have a list of drugs that cause grounds for automatic denial of your application if you use any of them. Typically, these medications treat severe or chronic illnesses.
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Frequently Asked Questions
What is Medicare Supplement underwriting?
Medicare Supplement underwriting refers to the evaluation process used by insurance companies to determine your eligibility for coverage. During underwriting, the insurance company may assess your health status and medical history to determine if they can offer you a Medicare Supplement plan and at what premium rate.
What types of underwriting eligibility questions are asked for Medicare Supplement plans?
Underwriting eligibility questions for Medicare Supplement plans typically inquire about your age, gender, tobacco use, pre-existing health conditions, and any recent hospitalizations or surgeries. These questions help the insurance company assess your risk profile and determine your eligibility for coverage.
What is the difference between guaranteed issue and medical underwriting?
Guaranteed issue means you have the right to enroll in a Medicare Supplement plan without undergoing medical underwriting. This right is typically granted during specific enrollment periods or in certain situations. Medical underwriting, on the other hand, involves the evaluation of your health history and may result in denial of coverage or higher premiums based on your health status.
What are the advantages of guaranteed issue Medicare Supplement plans?
Guaranteed issue Medicare Supplement plans provide coverage without medical underwriting, ensuring that you cannot be denied coverage or charged higher premiums based on your health status or pre-existing conditions. This can be especially beneficial if you have health conditions that may otherwise make it challenging to obtain coverage.
What are the eligibility criteria for guaranteed issue Medicare Supplement plans?
Eligibility criteria for guaranteed issue Medicare Supplement plans vary depending on the circumstances. Common situations that may trigger guaranteed issue rights include the loss of employer-sponsored coverage, certain plan cancellations, or moving out of your plan’s service area. It’s important to consult with an insurance agent or review the specific eligibility requirements for guaranteed issue in your state.
Is medical underwriting required for all Medicare Supplement plans?
Medical underwriting is not required for all Medicare Supplement plans. During certain enrollment periods or if you have guaranteed issue rights, you can enroll in a plan without undergoing medical underwriting. However, if you apply for a Medicare Supplement plan outside of these periods, medical underwriting may be required.
What is the difference in underwriting eligibility between Medicare Plan G and Plan N?
The underwriting eligibility requirements for Medicare Plan G and Plan N are typically the same. Both plans may require medical underwriting unless you qualify for guaranteed issue rights. It’s important to understand that underwriting eligibility may vary between insurance companies, so it’s advisable to compare multiple providers when considering these plans.
Can I be denied coverage based on my health condition during underwriting?
Yes, during underwriting, an insurance company may deny you coverage or charge higher premiums based on your health condition. However, if you have guaranteed issue rights or qualify for specific enrollment periods, you have protection against denial of coverage or higher premiums based on your health status.
Can I appeal a denial of coverage during underwriting?
If your application for Medicare Supplement coverage is denied during underwriting, you have the right to appeal the decision. The appeals process allows you to present additional information or documentation to support your case for coverage. It’s advisable to work with a licensed insurance agent or seek guidance from your state’s insurance department to understand the appeals process.
Where can I get assistance with Medicare Supplement underwriting eligibility questions?
If you have questions or need assistance with Medicare Supplement underwriting eligibility, it’s recommended to reach out to licensed insurance agents specializing in Medicare. They can provide guidance, help you understand the underwriting process, and assist in finding the most suitable Medicare Supplement plan for your needs.
Let Us Walk You Through Medicare Supplement Underwriting Eligibility Questions
If you want more information on medical underwriting and the process of enrolling in a Medigap plan, speak to our fully licensed agents. We’re available at 1-888-891-0229 for a free consultation and quote for joining any plan.
Our agents can advise you on the underwriting process and what to expect. If you can speak to us right now, leave your details on our contact form, and we’ll get a Medigap expert to call you back.
Russell Noga is the CEO and Medicare editor of Medisupps.com. His 15 years of experience in the Medicare insurance market includes being a licensed Medicare insurance broker in all 50 states. He is frequently featured as a featured as a keynote Medicare event speaker, has authored hundreds of Medicare content pages, and hosts the very popular Medisupps.com Medicare Youtube channel. His expertise includes Medicare, Medigap insurance, Medicare Advantage plans, and Medicare Part D.