Medicare Supplement Underwriting Eligibility Questions

If you’re changing Medigap plan or miss your Open Enrollment Period for a Medicare Supplement, it’s likely that Medicare Supplement underwriting will be required.

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

Most likely you’re wondering if you can be denied a Medicare Supplement insurance, the answer is that in many states, yes you can be denied coverage.

Medicare Supplement Underwriting Questions

In many states, you need to answer questions about your health and get through underwriting to qualify for new coverage. While medical underwriting can cause some stress, many individuals successfully pass underwriting and change coverage annually, so don’t worry.

Let’s dive into information about the situations typically resulting in approval. Then we can talk about when you may face hurdles changing plans. This information assists you in understanding if you’re Medigap eligible.

Guaranteed Issue Means No Questions about Health

Each Medicare Beneficiary has the Open Enrollment Period (OEP) for Medicare Supplement insurance when turning 65 and first activate their Part B.

In doing research on Medigap plans, you’ll know that the 6-month enrollment window allows you get to apply for a Supplement without answering health questions.

There are alternative situations where you’re guaranteed a right to purchase comprehensive Medicare Supplement Insurance without underwriting, this is called Guaranteed Issue, commonly shortened to “GI”.

These are some 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 Medicare Advantage coverage, you can dis-enroll. Then enroll in a Medicare 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 a Medicare Advantage plan.

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

Other possible circumstances could result in a GI period, talking to an insurance agent that is a Medicare Expert is the best option for you to identify GI eligibility.

Medigap’s Birthday Rule States

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

This does require that you have a Medicare Supplement policy currently active to qualify. If you talk to your agent, they can obtain quotes for your plan to check if a lower rate exists for you.

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

Washington allows Medicare 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 Medicare Supplements are much higher.

Medicare Supplement Underwriting

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

Basically, each insurance 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 certain condition, and others inquire about a more recent time period. Commonly, questions pertain 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 Medicare experts about the possibilities.

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

Small Health Problems May Result in Approval

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

Cholesterol and high blood pressure are also an unlikely issue if they’re not occurring with an additional and more serious problem.

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

The Body Mass Index isn’t as strict on Medicare 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 check your BMI to the company guidelines this way you don’t spend time applying when you’d otherwise be declined.

Finish Upcoming Treatments and Pending Surgeries First

Of course, there are situations that can cause a decline, and costly upcoming procedures are at the top of the list. It’s obvious that no insurance company wants to cover you prior to an expensive 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?”

There are carriers that inquire about a certain time frame clear post surgery, like a knee replacement. Since problems are possible, they could ask you to delay the process for the year or more before submitting an application.

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

Please, Wait if You had a Recent Major Services

If you’ve been hospitalized or if you received home health services two more times within the last couple years, it’s possible the carrier will 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 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 forever treatment, 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/or rhythm defects most carriers will decline coverage. In most circumstances’ organ transplants and/or kidney failure can indicate a decline.

Borderline Conditions

The way a carrier phrases these inquiries on their specific application will determine if you can successfully pass the Medicare 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 suffer from diabetes with high blood pressure and require 3 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 2 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.

Once the carrier has your report, they’ll look for any prescriptions that could indicate a condition that results in a decline for coverage.

It’s vital that you’re truthful and try to remember any of the medications that you were recently prescribed.

Auto-Decline Drugs

Of course, Medigap carriers have a form of medications that mean you’re automatically declined. These medications are ones that treat chronic or major illnesses.

Basically, if you take these medications you’re indicating that you have a health condition that could be costly for the carrier to cover.

Pain medications can be an issue if used if prolonged.

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

Medicare 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 Medicare 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 insurance carrier will incorporate in the assessment.

Submitting a Medicare Supplement Application

Here at MedicareFAQ, we have brokers that, when you’re 100% open with, can help you navigate to the most appropriate carrier with any specific health issues that you have. We will ask you this, so we know how we can best help you:

In the past 5 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 Medicare 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.

Canceling Coverage Before Approval of New Coverage

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

Your agent at MedicareFAQ will watch your pending application and notify you immediately after you receive that call, then you can contact your previous carrier to end current coverage.

Insurance 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, simply 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 Medicare benefits and medical underwriting questions.