What to Know About Medicare Supplement Underwriting

Underwriting is used by insurance carriers to determine whether to allow someone to enroll in a health plan or deny, restrict, or increase the cost of coverage. Medicare Supplement (Medigap) plans are offered by private insurance companies, which use the underwriting process to manage costs and avoid enrolling people at times other than Open Enrollment.

If you have to take part in Medicare Supplement underwriting, you’ll fill out a health history, and many carriers request access to your medical records or use databases to discover health information. Some people with chronic conditions may not get through underwriting, but many applicants do; and the process may be easier than you think.

What to expect during Medicare Supplement underwriting

If you want to enroll in a Medicare Supplement plan outside of a guaranteed-issue period, you’ll have to answer a Medigap health questionnaire. Insurance carriers use this to understand your risk of having a costly insurance claim down the road. Depending upon your responses to underwriting questions, the carrier can increase the cost of your plan or deny you coverage.

The process is probably simpler than you think, though. Underwriting usually consists of questions an agent will ask about your health. You’ll also need a list of your prescription medications. Along with your questionnaire, most carriers will run your information through programs that check your health history and prescription drug use. Some may ask to review your medical records or require you to take a physical.

Real Life Customer Example: One of our customers, Tom, assumed he was automatically disqualified, but had never actually been told that by anyone. One of our licensed insurance agents proceeded to walk through the health questions and explore carrier options. Tom finished cancer treatment in the past, and assumed he was automatically disqualified. However, depending on the carrier’s cancer lookback window (typically 2-5 years), he may need to wait, but isn’t permanently disqualified.

Every carrier is different, but there are some standard Medicare supplement underwriting questions you should be prepared to answer. These include:

• Your age and gender,
• Any alcohol, drug, or tobacco use or misuse,
• If you have chronic health conditions,
• If you have had, or need to have, major medical care like a hospitalization or surgery,
• What prescription medications you take,
• Your family health history,
• Your physical and mental health history,
• Your weight or body mass index.

When you may be declined Medigap coverage

Every insurance carrier has a different policy regarding what conditions disqualify enrollees from being accepted into a Medigap plan. But some are more likely to be on that list than others. Frequent Medigap declinable conditions include:

• AIDS,
• Alzheimer’s and other cognitive conditions,
• Current cancer treatment or a history of cancer,
• Cirrhosis,
• COPD,
• Congestive heart failure, stroke, or history of a heart attack,
• Uncontrolled diabetes,
• Kidney failure or end-stage renal disease,
• Neurological disorders like multiple sclerosis and Parkinson’s disease.

Minor health conditions like allergies, high cholesterol. and high blood pressure (that is well managed by medications) usually won’t disqualify you from enrolling in a plan. For some conditions, carriers will have a lookback period that’s usually two to five years. For instance, if you had a stroke three years ago and have recovered, or have been cancer-free for five years, you could still be approved.

Strategies to increase your odds of approval for Medigap

There are a couple of ways you can increase your odds of getting approved for a Medigap policy outside of guaranteed-issue periods. First, look up your state’s guidelines. Several states have different rules that let people enroll in Medigap without going through underwriting.

• Continuous enrollment in states including New York, Maine, Vermont, and Massachusetts either lets plan members switch at any time without underwriting or do so with some restrictions.
• Annual birthday or policy anniversary states like California, Idaho, Illinois, Nevada, Oregon, and Rhode Island allow you to change to a similar, or less abundant, plan (like moving from a Plan G to a Plan N) each year. You’ll have a set number of days, usually 30 to 60, around your birthday or policy enrollment date.

You may also have better luck switching to a Medigap plan when you work with an independent broker. Brokers often know the underwriting criteria for different carriers and can steer you toward one that is more likely to accept you at a reasonable cost. Brokers can also go through the assessment with you over the phone and submit it to a carrier.

Real Life Customer Example: A couple, William and Betty, spoke with one of our agents together about their coverage. The couple’s health concerns were minor — no major conditions, some possible kidney stones for Betty, and minimal medications. The agent immediately reassured them and set expectations that underwriting is a step in the process, not a brick wall. He also explained the flow: sit down together, answer questions, submit, and wait for the carrier’s decision.

When is Medigap underwriting waived?

You can join or switch to Medigap without underwriting when you first turn 65 and enroll in Medicare Part B, and during possible Special Enrollment Periods (if you qualify). During these times, you have Medigap guaranteed issue rights. This means carriers must:

• Accept you for the plan of your choice,
• Cover any pre-existing conditions you have,
• Provide the plan for the same cost as any other beneficiary (they can’t increase your premiums because of your health conditions).

Medigap Open Enrollment Period. This is the time you enroll in Medicare at age 65 – it begins the first day of the month you are enrolled in Part B and lasts six months. During this period, you can enroll in any Medicare Supplement plan with any carrier with guaranteed issue. Some insurers also let you submit a Medigap application a few months before your official open enrollment, so it’s a good idea to start looking early.

You are also allowed a guaranteed issue of a Medicare Supplement plan during a few other times known as special enrollment. These include:

• If you are on Medicare Advantage and your plan leaves your area,
• If you move and your current plan isn’t offered in your new location,
• If you are over 65 and have employer coverage that is ending,
• If you drop out of a Medicare Advantage plan within 12 months of your Initial Enrollment Period (when you turn 65).

It can be especially difficult with one or more pre-existing conditions to find a health plan that covers your treatment and prescription needs at a price you can afford. But good Medicare coverage isn’t impossible. Working with a licensed agent from UnitedMedicare Advisors can give you a leg up on finding the right Medigap plan. Good advisors know what carriers are looking for and can steer you toward a plan that meets your specific healthcare needs. Don’t assume you won’t pass underwriting; talk with an agent first to see typical premium rates in your state.

Disclaimer: Customer examples are based on real call transcripts with names and identifying details changed to protect privacy. Medical conditions discussed are strictly illustrative to explain underwriting concepts and do not guarantee insurance outcomes or constitute medical advice.