Medicare Supplement Underwriting Eligibility Questions

Last Updated on August 26, 2020 by Lindsay Engle

Medicare Supplement underwriting questions aren’t always mandatory. Sometimes, like during your Open Enrollment Period (OEP), you receive a waiver for health question requirements.

If you’re changing Medigap plan or miss your OEP, Supplement underwriting is likely a must.

Maybe you’re paying for a Medigap plan, and the rates are going up. Perhaps you enrolled in Plan G, and you’re feeling that Plan N would be more suitable.

Most likely, you’re wondering if you can be denied Supplement insurance, in many states, yes.

Guaranteed Issue Means No Questions about Health

Each Beneficiary has a Medigap Open Enrollment Period when turning 65 and first activate their Part B.

After Medigap research, you’ll learn the 6-month enrollment window allows you to apply for a Supplement without underwriting.

Alternative situations are allowing for a policy without underwriting; this is Guarantee Issue rights.

These are Guaranteed Issue examples: 

1. Leaving insurance with a large employer in the last 63 days, typically employer coverage.
2. During the 12 months of first enrolling in Advantage coverage, you can dis-enroll. Then enroll in a Supplement; instead, this is called the Medicare Advantage trial period.
3. If you move out of your plans service area and you have a Medicare Select policy or an Advantage plan.

Each of these scenarios offers beneficiaries a short time frame to apply for a Supplement policy with Guaranteed Issue.

Other situations could result in a GI period; talking to an agent is the best way to identify GI eligibility.

Medigap’s State Birthday Rule

Oregon and California allow beneficiaries to change their Supplement policy within the birthday month with no Supplement underwriting.

This does require that you have a Supplement policy currently active to qualify. Talk to your agent; they can get quotes to check if a lower rate exists.

If you find a good deal, the application process is quick and easy, especially when there are no medical underwriting questions.

Washington allows Supplement eligibility all year; this means that anyone could be applying at any time and receive coverage. This also means that rates in Washington for Supplements are much higher.

Understanding Medicare Supplement Underwriting Questions

Now you’re an expert with Guaranteed Issue situations! What you need to know is how underwriting is done through the carriers.

Each carrier has a minimum of one form of health-related questions included in its Medigap application.

Some of the questions ask if you’ve EVER had a particular condition; however, others inquire about a more recent time. Commonly, questions about the last couple of years of health history.

Answering NO to a few or all the medical questions as specified on the applications is recommended.

If you answer YES to an inquiry, it can result in an instant decline for most carriers. This means you’re not qualified for any coverage, and there is no need to apply.

Depending on state laws and specific carrier exceptions, it’s best to talk to one of our experts about the possibilities.

Through the next sections, I’ll cover some examples of questions that exist in Supplement applications.

Small Health Problems May Result in Approval

When you’re fully healed and done with treatment, then specific injuries are no issue. You will also notice the companies don’t care if the flu got you twice this year or seasonal allergies.

Cholesterol and high blood pressure are unlikely issues when not occurring with a further or more serious problem.

For example, minor arthritis isn’t problematic, but more severe rheumatoid arthritis could indicate a decline in coverage.

The Body Mass Index isn’t as strict on Supplement plans as it is with life insurance. Having those few extra pounds isn’t an issue if you aren’t morbidly obese.

Each company has underwriting guidelines, and your broker will company guidelines; this way, you don’t spend time applying when you’d get a denial.

Finish Upcoming Treatments and Pending Surgeries First

There are denial situations, and upcoming procedures are at the top of the list. No company wants to cover you before a costly test or surgery.

Carriers insist that you receive your treatments covered with your previous carrier before applying for new coverage.

Even when your upcoming surgery is not life-threatening, you’ll still need to wait to apply. It’s best to complete your surgery and all follow-up appointments or any required therapy. Once that’s complete, then apply for the new carrier.

Example question from one of our carrier’s applications:

“Within the last 12-months, have you been advised to have treatment, diagnostic testing, further evaluation, or any surgery that hasn’t been performed?”

Some carriers ask about a specific time frame clear post-surgery, like a knee replacement. Since problems are possible, they can ask you to delay the process for the year or more before applying.

These kinds of requirements vary, and it’s best to ask one of our experts which carriers give you the best chance.

Please, Wait if You had Recent Major Services

If you’ve been hospitalized or if you received home health services two more times within the last couple of years, the carrier may decline you during the application. If you live in a nursing home, you most likely won’t be eligible.

People rarely go from a nursing home or assisted living facility to live independently. You may need to keep your coverage indefinitely.

Sample question from a carrier:

“Are you hospitalized, in a nursing facility or assisted living facility, confined to a bed, receiving home health care, or any physical therapy?”

Cancer is a common concern among applicants. Most carriers want to see at least two years of cancer-free and successful remission before they’ll consider covering you. If you’ve had a recent surgery or you are going through any treatments, you’ll want to wait a couple of years before applying.

Keep Your Coverage if you have a Chronic, Incurable Condition

There are plenty of health issues that can be treated but are still considered incurable illnesses. When you have an illness that requires treatment forever, you’ll see that there are questions on many Medicare Supplement applications that can exclude you.

Several common examples include:

• Chronic lung problems
• Dementia
• Immune deficiency disorders like MS, RS, AIDS, or Lupus.
• Nervous system issues, like Parkinson’s

If you have osteoporosis and fractures, this could be problematic. Insurance companies know conditions like this will require a lifetime of care costs.

Heart disorders like this could cause a decline:

• Heart attack
• Stents
• Strokes
• Arterial and vascular diseases
• Pacemakers
• Congestive heart failure

For valve problems and rhythm defects, most carriers will decline coverage. In most circumstances’ organ transplants and kidney failure can indicate a decline.

Medicare Supplement Underwriting Questions for Borderline Conditions

The way a carrier phrases these inquiries on their specific application will determine if you can successfully pass the Supplement underwriting.

An example of a common borderline condition would be diabetes and Mental Health.

If you only take the oral medication or you take less than 50 units of insulin, you should receive approval. When you have diabetes, carriers look at additional conditions.

So, if you have high blood pressure and diabetes with high cholesterol or diabetic neuropathy, then it’s harder to receive approval for coverage.

If you only have diabetes and no related conditions, you should be able to change carriers.

Sample question:

“Do you have diabetes with high blood pressure and require three or more high blood pressure medications to maintain control. Does your diabetes require more than 50 units of insulin each day to control?”

Mental conditions can also be a good example. Typically, if you see a therapist and you take a simple anti-depressant, that isn’t an issue when you have a more severe mental disorder that can cause a decline.

Sample question:

“Have now or within the last two years received treatment for (including surgery), or were you advised by a healthcare professional to receive treatment for severe depression, schizophrenia, a paranoid disorder, or bipolar disorder?”

Declined for Medications

Prescription history records are available to Medigap carriers. On your application, you’ll want to allow the new carrier to obtain your prescription records.

You must be truthful and try to remember any of the medications that you were recently prescribed.

Auto-Decline Drugs

Of course, Medigap carriers have a list of medications that indicate automatic denial. These medications are ones that treat chronic or significant illnesses.

If you take these medications, you’re indicating that you have a condition that could be costly to cover. Pain medications can be an issue if used if prolonged.

If you take a small round of Vicodin for a post-surgery, the company won’t consider this a problem. If you’ve been using it for years, then that could be a potential issue.

Supplement carriers don’t like to take a gamble on this—other problematic pain medications, including fentanyl, oxycontin, morphine, and oxycodone.

Here is a list of some covered drugs covered by Part D.

Medical Records

Most people don’t know what’s in their medical record history. Think carefully; if a doctor is telling you that you’re pre-diabetic, you’ll need to ask him what he’s submitting to your file. Was the doctor sugar-coating the health condition during the discussion with you?

Telling you that you’re pre-diabetic is less significant, it’s what exists in your file that is key. If your health chart says diabetes, that’s what the carrier will incorporate in the assessment.

Submitting a Medicare Supplement Application With Underwriting Questions

We have agents that can help you find the best carrier for any specific health issues.

We will ask you this, so we know how we can best help you:

In the past five years, have you been diagnosed, received treatment for, or take any prescribed medications for:

• Cancer
• Heart Attack or any heart issues such as a Pacemaker or Defibrillator
• Stroke or TIA
• AFIB (Atrial Fibrillation)
• COPD
• Diabetes
• Disabling Arthritis
• Stent Placement
• Prescribed any Blood Thinner medications
• Pending Surgery

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.

Identifying the best company for you is simple, and applying is so easy that it can be done over the phone.

Switching Supplements is timely, so you should apply for an effective date around 2-3 weeks away. This will give the underwriting department some time to finish your application.

You should expect an underwriter to call you; the telephone interview is a vital part of the carrier’s decision process.

Common Health Issues Medigap Declines

If you have any of the following health conditions, it’s likely a decline will come from your application. Although talking with an agent can help clear the air.

These conditions are usually an automatic decline:

• Aids
• ALS
• Alcohol/Drug Abuse
• Alzheimer’s Disease
• Dementias
• Chronic Bronchitis
• COPD
• Cystic Fibrosis
• Cirrhosis
• Congestive Heart Failure
• Diabetes
• Emphysema
• End-Stage Renal Disease (ESRD)
• Fibromyalgia
• Heart Disease
• Hepatitis
• Immune Disorders
• Multiple Sclerosis
• Lupus
• Kidney Disease requiring dialysis
• Mental/ Nervous Disorder
• Myasthenia Gravis
• Organ Transplant
• Osteoporosis
• Stroke
• Advised to have surgery/ Treatment
• Implantable Cardiac Defibrillator
• Use of Supplemental Oxygen
• Use of Nebulizer
• Asthma with three or more medications

Get Help Understanding Medicare Supplement Underwriting Questions

This is very important; you should never cancel your current coverage before you are approved with your new carrier.

Your agent will notify you so you can contact your previous carrier to end coverage.

Agents can’t cancel your prior coverage, this rule protects you, and you should never assume your agent will cancel previous coverage.

To contact an agent licensed in your area, 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 benefits and medical underwriting questions.