Medigap, also known as Medicare Supplement Insurance, is designed to cover the gaps in Original Medicare (Part A and Part B), such as your copayments, coinsurance, and deductibles.
If you enroll in Medigap during your initial six-month enrollment eligibility period, you don’t have to worry about getting turned down. During this period, you have guaranteed enrollment privilege. That means the insurance carrier must accept you as long as you pay your premiums. They cannot turn you down or charge you extra due to your medical history.
However, once your initial six-month guaranteed enrollment period expires, your medical history becomes a factor.
Not everyone can qualify for a Medigap policy. If you wait too long without enrolling, Medigap carriers can look at your medical history to decide whether they will issue a policy, and how much premium to charge you––a process called medical underwriting.
If you have a history of health problems when you apply for Medigap, you could be charged a higher premium or declined altogether.
This article will provide a comprehensive overview of what you need to know about Medigap medical underwriting if you want to enroll in a new Medigap plan after your initial open enrollment period.
Medigap Open Enrollment Period
Your Medigap open enrollment period begins when you are both age 65 or older and you enroll in Medicare Part B.
Your Medicare Part B enrollment triggers the start of your one-time, six-month Medigap open enrollment period, which begins on the first day of the following month.
The best time to purchase a Medigap policy is during your once-in-a-lifetime six-month guaranteed eligibility period when you first enroll in Medicare Part B. Buying when you’re first eligible ensures you can obtain the coverage you need without the potential complications and barriers posed by medical underwriting.
Unless you qualify for a limited exception (I’ll discuss these below), enrolling in a Medigap plan after your six-month initial guaranteed enrollment privilege expires means you’ll need to pass medical underwriting, to make sure you don’t pose an undue risk, which drives up costs for your fellow policyholders.
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Medigap Standard Eligibility Questions
When applying for a Medigap policy, insurance companies typically require applicants to answer a series of underwriting questions.
These questions are designed to assess the applicant’s health status and determine the risk of future medical claims. Here are the standard eligibility questions and considerations:
- Age. Your age can affect your eligibility and the cost of the policy.
- Alcohol Abuse. Questions about your history of alcohol use or abuse.
- Chronic Health Conditions. This includes conditions like diabetes, heart disease, and other long-term illnesses.
- Circulatory System. Questions about any issues related to your circulatory system, such as high blood pressure or cholesterol levels.
- Drug Use. This includes both prescription and over-the-counter medications, as well as any history of drug abuse.
- Gender. Some policies may consider gender in their risk assessment.
- Family Health History. Information about the health history of your immediate family members.
- Medical History. A comprehensive overview of your past medical conditions and treatments.
- Mental Health History. Questions about any mental health conditions you may have.
- Tobacco Use. Whether you currently use or have used tobacco products.
- Weight or Body Mass Index (BMI). Your current weight and height to calculate your BMI, which can affect your eligibility and premiums.
Health and Weight Criteria
Insurance companies often consider your height and weight when determining your eligibility for a Medigap policy.
This is because certain weight ranges can be associated with higher health risks. If your weight falls outside the acceptable range for your height, you may face higher premiums or be denied coverage altogether.
Health Criteria
Chronic Health Conditions
- Conditions such as dementia, chronic lung disorders, immune disorders (e.g., rheumatoid arthritis, multiple sclerosis, lupus, AIDS), and nervous system disorders (e.g., Parkinson’s disease) are likely to result in a decline due to the likely need for a lifetime of expensive care.
- Major heart disorders, including arterial and vascular diseases, a history of heart attacks, strokes, stents, pacemakers, and congestive heart failure, can also lead to a decline.
- Kidney failure and organ transplants are typically disqualifying conditions.
Recent Major Medical Incidents
- You may be declined if you have been hospitalized two or more times in the last two years or are receiving home health care.
- Pending surgeries and treatments must be completed before applying. This includes non-life-threatening surgeries like endometriosis or gallbladder removal.
Cancer and Serious Conditions
- Carriers usually require at least two years of being cancer-free and in remission before considering an application.
- Recent surgeries or ongoing treatments will necessitate waiting a few years before applying.
Minor Health Conditions
- Conditions like seasonal allergies, the flu, minor injuries, high blood pressure, and cholesterol are generally not issues unless accompanied by more serious conditions.
Borderline Conditions
- Some conditions may be borderline, depending on the carrier and how they phrase the related questions on their application. These could go either way in terms of approval.
Height and Weight Criteria
- When it comes to obtaining supplemental Medicare coverage through Medigap plans, the criteria surrounding body mass index (BMI) tend to be less stringent compared to other types of insurance policies, such as life insurance. For most Medigap carriers, being slightly overweight or carrying a few extra pounds is generally not a disqualifying factor, unless an individual falls into the category of extreme or morbid obesity.
- Each insurance company offering Medigap plans has its own specific underwriting guidelines that outline acceptable ranges for height and weight measurements. These guidelines are designed to ensure that applicants meet certain BMI thresholds to qualify for coverage. An experienced insurance agent can assist you in evaluating your height and weight against the carrier’s underwriting criteria, providing guidance on whether your BMI would potentially lead to a denied application or not.
Prescription Medication and Chronic Conditions
The underwriting process heavily considers both your use of prescription medications and any chronic conditions you may have.
For instance, if you have diabetes, insurers will assess whether it is well-managed.
Effective diabetes management usually involves maintaining blood sugar levels within a specified range through medication, diet, and exercise. Conversely, poorly controlled diabetes can lead to complications and might result in the denial of your application.
Disqualifying Conditions
When applying for a Medigap policy, it’s essential to be aware that some health conditions may result in disqualification.
While the specific conditions can differ from one insurance carrier to another, they typically encompass serious health issues such as immune system disorders, significant cardiovascular problems, and severe mental health conditions. It’s always advisable to discuss your unique health situation with potential insurers to determine your eligibility for coverage.
Differences Among Insurance Carriers
Insurance carriers exhibit diverse underwriting standards, which can significantly impact policy approval and premium rates.
Certain carriers may adopt a more lenient approach towards specific conditions, including smoking, pre-existing health issues, diabetes, and weight-related concerns. Therefore, it is crucial to thoroughly research and compare various carriers to identify one that is more accommodating to your unique health circumstances.
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Medigap Underwriting Conclusion
Comprehending the intricacies of Medigap can be complex, but familiarizing yourself with the key elements of open enrollment, medical underwriting, guaranteed issue rights, and state-specific rules can help you make informed decisions.
Remember to take advantage of your one-time, 6-month Medigap open enrollment period to avoid medical underwriting and secure the best possible plan. If you need to change plans or did not enroll during your initial enrollment period, review your guaranteed issue rights and consider consulting a Personal Benefits Manager for advice on suitable carriers.
By staying informed and proactive, you can find a Medigap policy that meets your needs and provides peace of mind.
How to Use Your PBM
Your Personal Benefits Manager can be valuable in identifying which carriers may be lenient with your particular condition.
Our Personal Benefit Managers possess a wealth of information on various insurance providers and can assist you throughout the underwriting process. They offer valuable insights into which insurers are more accommodating towards individuals who smoke and have pre-existing health conditions, diabetes, weight concerns, and other medical issues.
Unsure about selecting the right plan? Schedule a free consultation with one of our Personal Benefits Managers. We can save you time, money and stress, and guide you through the process from soup to nuts.
For Further Reading: Medi-Share 65+: A Health Sharing Alternative for Medicare Beneficiaries|What is Medicare Part B?|Can I get Medigap insurance if I’m under 65?
Tom Lockwood is a Personal Benefits Manager at MediGap Advisors. Tom has a passion for bringing clarity to those confused about Medicare. He is an authority on Medicare, Medicare supplement plans, Medicare Advantage plans, and Part D prescription drug plans. Read more about Tom on his Bio page.