Medigap Medical Underwriting: When You Can Be Denied Coverage and How to Avoid It

Unlike Original Medicare -- which cannot deny coverage based on health -- Medigap insurers can use medical underwriting outside of guaranteed issue periods. This means they can ask about your health history, charge higher premiums, exclude pre-existing conditions, or deny coverage entirely. Understanding when underwriting applies and how to avoid it is critical.

Medical underwriting is the process by which an insurance company evaluates your health history to determine whether to offer you coverage, and at what price. For Medigap, underwriting can result in:

• Approval at standard rates
• Approval with a higher premium (rated up for health conditions)
• Approval with a pre-existing condition waiting period (up to 6 months)
• Denial of coverage for specific conditions or entirely

During guaranteed issue periods, Medigap insurers must sell you any plan they offer at standard rates -- no health questions, no denials.

Medigap Open Enrollment Period (most important): The 6-month window beginning the month you are both age 65 and enrolled in Part B. This is the single most important guaranteed issue period -- enroll during this window and you cannot be denied or charged more based on health.

Other guaranteed issue situations:

• Your Medicare Advantage plan leaves Medicare or stops serving your area
• You move out of your MA plan's service area
• Your employer retiree coverage ends
• You enrolled in MA when first eligible and want to switch back within 12 months (trial right)
• Your Medigap insurer goes bankrupt or commits fraud

Outside of guaranteed issue periods, Florida Medigap insurers can use medical underwriting. Common situations where underwriting applies:

• Enrolling in Medigap more than 6 months after turning 65 and enrolling in Part B
• Switching from one Medigap plan to another outside a guaranteed issue period
• Enrolling in Medigap after returning from Medicare Advantage (outside trial right period)
• Enrolling in Medigap under age 65 (disability Medicare)

Underwriting standards vary by insurer, but conditions that frequently result in denial or higher premiums include:

• Recent cancer diagnosis or treatment
• Heart disease, recent heart attack, or heart surgery
• Stroke or TIA within the past 2 years
• COPD or emphysema requiring oxygen
• Kidney failure or dialysis
• Alzheimer's disease or dementia
• Diabetes with complications
• Morbid obesity
• Recent major surgery

Florida provides some additional Medigap protections beyond federal requirements:

Under-65 Medigap: Florida requires insurers to offer at least one Medigap plan to Medicare beneficiaries under 65 (disability Medicare) -- though they can charge higher premiums.

Birthday rule: Florida does not currently have a birthday rule (unlike California and Oregon), which would allow annual plan switching without underwriting.

Enroll during your Open Enrollment Period: The most important strategy -- enroll in Medigap during your 6-month guaranteed issue window at 65. Do not delay.

Think carefully before switching to Medicare Advantage: If you leave Medigap for MA and later want to return to Medigap, you will likely face underwriting (unless within the 12-month trial right period).

Use guaranteed issue rights promptly: Guaranteed issue rights have deadlines -- typically 63 days from the triggering event. Act quickly when a qualifying event occurs.

We do not offer every plan available in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.