The phrase “medical underwriting” might sound daunting, especially when you’re researching Medigap plans. Whether you’re aging into Medicare, switching from a Medicare Advantage plan, or experiencing a qualifying life event, understanding this process is key. We’ll break down what Medigap underwriting means, why it’s important, and how it could affect your plan options.

Medigap 101: Why Medical Underwriting Matters

Medigap, also known as Medicare Supplement Insurance, helps fill the “gaps” in Original Medicare (Parts A and B) coverage. It helps pay for out-of-pocket costs like deductibles, copayments, and coinsurance, providing valuable financial protection.

However, unlike Original Medicare, Medigap plans are offered by private insurance companies, and these companies use a process called medical underwriting to assess your health risk before offering you a policy. The medical underwriting process helps them determine your premium costs or even your eligibility for coverage.

Understanding Medigap underwriting is crucial because:

• It affects your premium: Your health status can significantly influence how much you pay for a Medigap plan.
• It can impact your eligibility: In some cases, you might be denied coverage altogether due to pre-existing health conditions.
• It helps you make informed decisions: Knowing the process of underwriting helps you choose the right plan for you at the right time.

Medigap Open Enrollment: Your Guaranteed Issue Window

“Best” is a subjective term, but there’s not a debate here: The best time to enroll in a Medigap plan is during your Medigap Open Enrollment Period. This is a one-time, six-month window that starts when you turn 65 and are enrolled in Medicare Part B.

During this period, you have guaranteed issue rights, which means:

• No medical underwriting: Insurance companies cannot deny you coverage or charge you higher premiums based on your health status.
• More plan choices: You have access to all Medigap plans available in your state.

Important Note: If you’re switching from Medicare Advantage to Medigap, you typically do not have guaranteed issue rights outside of certain specific circumstances (more on this later).

Medigap Underwriting Demystified: What to Expect

Outside of your Medigap Open Enrollment Period, you’ll likely face medical underwriting when applying for a Medigap plan. This process typically involves:

• Health questionnaire: You’ll be asked questions about your medical history, current health conditions, and medications.
• Medical records review: The insurance company may request access to your medical records to verify the information you provide.
• Medical exam: In some cases, you may be required to undergo a physical exam.

Based on the underwriting assessment, the insurance company can:

• Approve your application: Offer you the Medigap plan at the standard premium rate.
• Approve with a higher premium: Offer you the plan, but at a higher cost due to your health risks.
• Deny your application: Refuse to offer you coverage due to your health status. This is often referred to as a “Health Knockout.”

According to the Kaiser Family Foundation, the list of “potentially deniable medical conditions” includes:

• Alzheimer’s disease
• Asthma
• Cancer
• Congestive heart disease
• Diabetes with complications
• End-stage renal disease (ESRD)
• High blood pressure
• Limitations of daily activities
• Stroke

(Some of these conditions, however, may potentially qualify you for a Medicare Advantage Chronic Condition Special Needs Plan.)

What About The Affordable Care Act and Pre-Existing Conditions?

This might sound strange, as the Affordable Care Act (colloquially known as “Obamacare”) does not allow insurers to deny coverage or increase premiums based on pre-existing conditions, as of March 2025. However, these protections do not apply to Medicare Supplement plans.

Guaranteed Issue Rights: When Underwriting is Waived

Even outside your open enrollment period, there are certain situations where you have guaranteed issue rights and cannot be denied Medigap coverage or charged higher premiums due to your health. These situations include:

• Loss of creditable coverage: If you lose coverage from an employer, union, or other source that’s considered “creditable,” you have the right to buy a Medigap plan.
• Medicare Advantage trial period: If you join a Medicare Advantage plan when first eligible for Medicare and decide to switch back to Original Medicare within the first year, you have guaranteed issue rights.
• Medicare Advantage plan issues: If your Medicare Advantage plan leaves Medicare, stops providing services in your area, or you move out of their service area, you have guaranteed issue rights.
• Medigap plan issues: If your Medigap insurer goes bankrupt or your coverage ends for reasons outside your control, you have guaranteed issue rights.
• Medicare Advantage plan misconduct: If you leave your Medicare Advantage plan due to the company not following rules or misleading you, you have guaranteed issue rights.

If you’re looking for a full list of situations that may afford you guaranteed issue rights, Medicare.gov has a short survey that gives you an answer.

Navigating the Medigap Medical Underwriting Process: Tips for Success

If you’re facing Medigap underwriting, here are some tips to increase your chances of approval:

• Be prepared: Collect your medical record. This should include dates of diagnoses, treatments, and medications.
• Be thorough: Answer all health questions honestly and completely. Don’t leave anything blank or say “I don’t know” if you can avoid it.
• Be proactive: If you have any pending medical procedures or tests, consider completing them before applying for Medigap.
• Be honest: Disclose all health conditions and medications, even if you think they might be disqualifying.

While some conditions might make it more challenging to get approved, it’s always worth applying. Insurance companies have some flexibility, and you might qualify for a plan even with pre-existing conditions. If you’re curious what potential questions you may be asked, the underwriting questions for Aetna’s Medicare Supplement application begin on Page 4 of this document.

Denied Coverage Due To Underwriting? You Have Options

If your Medigap application is denied, it doesn’t mean your options are over. Here are some steps you can take:

• Appeal the decision: Each insurer has an appeal process. Contact them to learn more.
• Contact Medicare: Call 1-800-MEDICARE (800-633-4227) for assistance.
• Seek help from SHIP: Your State Health Insurance Assistance Program (SHIP) offers free, unbiased counseling on Medicare and Medigap issues.
• Consider alternatives: Explore other options like Medicare Advantage plans, but be aware of their differences between Medigap plans (networks, prior authorizations, etc.).

Why We’re Here: This can be a difficult process, but a licensed insurance agent at SmartMatch can also help you through the process. Whether you’ve applied for a plan through another agent, or did it on your own, we can assist in exploring options should you be denied coverage.

State-Specific Underwriting Considerations

It’s important to note that Medigap regulations can vary from state to state. Some states have more generous guaranteed issue rights or offer additional protections for consumers. One of the clearest examples of this is the Birthday Rule, which provides guaranteed issue rights usually around a beneficiary’s birthday.

To learn more about the rules in your state, contact your state insurance department or SHIP.

Key Takeaways: Empowering Your Medigap Choice

Medigap underwriting can seem complex, but understanding the basics empowers you to make informed decisions about your healthcare coverage. Remember these key points:

• Medigap Open Enrollment is key: Take advantage of your guaranteed issue rights during this time.
• Know your rights: Understand when you have guaranteed issue rights outside of open enrollment.
• Be prepared for underwriting: Gather your medical information and be honest in your application.
• Don’t give up: If you’re denied coverage, explore your options and seek help from resources like SHIP or a trusted licensed insurance agent.

By being proactive and informed, you can navigate the Medigap underwriting process with confidence and find the plan that best meets your needs and budget. If you’d like hands-on guidance, contact us at SmartMatch to discuss your options and get expert advice.