Turning 65 is a milestone that brings many changes, and for most, the transition to Medicare is the most significant. You have likely heard that Medicare Supplement plans (Medigap) offer incredible peace of mind by covering the gaps left by Original Medicare, such as copayments, coinsurance, and deductibles. It is true: these plans provide financial security and predictability.
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However, obtaining this coverage is not always automatic. Depending on when you apply, your health history can play a major role in your eligibility and costs. This process is known as Medigap underwriting. Understanding how it works is essential to securing the best coverage for your future.
What Is Medigap Underwriting?
Medical underwriting is a process insurance companies use to evaluate your health status before they agree to sell you a policy. During this review, the insurer looks at your medical history, current health conditions, and prescription drug usage.
Based on this information, the insurance company decides whether to accept your application, how much to charge you for the premium, or if they will deny coverage altogether. While this sounds intimidating, it is standard practice for insurance policies purchased outside of specific protected enrollment periods. The goal for the insurer is to assess the risk of future medical claims.
When You Can Avoid Underwriting: Guaranteed Issue Periods
The good news is that there are specific times when you can bypass medical underwriting entirely. The most important of these is your Medigap Open Enrollment Period. This is a one-time, six-month window that begins the first month you are 65 or older and enrolled in Medicare Part B.
During this “golden ticket” period, insurance companies must sell you any Medigap plan they offer in your state. They cannot deny you coverage or charge you more due to your health history. This is why we always recommend enrolling during your Open Enrollment Period if possible—it is the easiest way to secure comprehensive coverage without health questions.
For more information on your Medicare Supplement Open Enrollment Period, please visit Medicare Supplement (Medigap) Open Enrollment Period.
How Pre-existing Conditions Affect Your Ability to Get Coverage
If you apply for a Medigap plan outside of your Open Enrollment Period or a Guaranteed Issue window, your pre-existing conditions become a factor. A pre-existing condition is generally defined as any health issue you have been diagnosed with or treated for prior to applying for a new policy.
In these cases, insurance companies can use medical underwriting to review your application. If you have serious chronic conditions, the insurer may decline your application. This is why securing a plan when you are first eligible is so critical. It ensures you have the coverage you need, regardless of how your health changes in the future.
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Underwriting Questions: What Insurers Typically Ask
When you undergo underwriting, you will need to answer a series of health questions on the application. While each insurance company has its own specific questionnaire, they typically ask about:
- Recent hospitalizations or surgeries.
- Heart conditions (e.g., heart attack, stroke, atrial fibrillation).
- Cancer history (usually looking back 2 to 5 years).
- Chronic lung diseases like COPD or emphysema.
- Diabetes, especially if complications or insulin use are involved.
- Neurological disorders like Parkinson’s disease or Multiple Sclerosis.
You will also likely need to list your current medications. Insurers often use this medication history to cross-reference your answers and identify any undisclosed conditions.
Preexisting Condition Waiting Periods: What Are They and When They Apply?
Even if a company accepts your application, they may impose a pre-existing condition waiting period. This is a period of time -typically up to six months- where the plan will not cover out-of-pocket costs related to a condition you had before the policy started.
However, you can often avoid this waiting period. If you have had “creditable coverage” (like a group health plan) for at least six months prior to applying, the insurer must credit that time toward the waiting period. In many cases, this eliminates the waiting period entirely, allowing your full benefits to start immediately.
Why Some States Do Not Allow Medigap Underwriting
While federal laws set the baseline, some states have implemented their own rules to offer stronger consumer protections. States like New York, Connecticut, and Massachusetts have “continuous open enrollment” or similar laws. In these states, insurance companies generally must sell you a policy at any time of year, regardless of your health.
Other states, such as California and Oregon, have “Birthday Rules.” These allow existing Medigap policyholders to switch to a plan with equal or lesser benefits around their birthday each year without undergoing medical underwriting. It is important to check the specific rules in your state, as they can significantly impact your flexibility.
For a list of states offering “Birthday Rules”, please see Can Medicare Be Used in Any State?
How Underwriting Impacts Medigap Pricing
Medical underwriting does not just determine if you get coverage; it also determines how much you pay. If you are subject to underwriting, insurers may offer you a rate based on your health status.
- Preferred Rate: The lowest premium, available to non-smokers in excellent health.
- Standard Rate: A slightly higher premium for those with some minor health issues or tobacco use.
- Substandard Rate: A higher premium for those with higher-risk health conditions (if the insurer accepts the application).
Securing a policy during your Open Enrollment Period ensures you get the best available rate for your age and location, without health surcharges.
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Switching Medigap Plans Later: The Hidden Challenges
Many beneficiaries assume they can buy a basic plan now and switch to a more comprehensive plan, like Plan G, if they get sick later. This is a risky strategy. Once your initial Open Enrollment Period ends, you generally cannot switch plans without passing medical underwriting (unless you live in a specific state with special rules).
If your health declines, you may find yourself “locked in” to your current plan because other insurers will not accept your application. This emphasizes the value of choosing the right comprehensive coverage from the start.
Strategies for Applicants with Preexisting Conditions
If you have pre-existing conditions and are outside your open enrollment window, do not lose hope. You still have options:
- Check for Guaranteed Issue Rights: Did you recently lose other coverage? You might qualify for a protected enrollment period.
- Apply to Lenient Carriers: Some insurance companies have more lenient underwriting guidelines than others. An experienced agent knows which carriers are most likely to accept specific conditions.
- Maintain Continuous Coverage: ensuring you do not have gaps in coverage helps you avoid waiting periods.
